07010156BUILDING DIVISION PEI T I CONTA A CJK
BUILDING ADDRESS: PERMIT NO.
20380 STEVENS CREEK BLVD TBD - TO BE DETERMINED 107010156
OWNER'S NAME:
PROMETHEUS RE GROUP
PHONE:
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
ARCHITECT /ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB b4ECH
ed c p LICENSED CONTRACTOR'S DECLARATION
P I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
? U U with Section 7000) of Division 3 of the Business and Professions Code, and my license is
t �<� in full force and effect
r ? License Class Lic. N
F, in Date Contractor
ARCHITECTS DECLARATION
7 ode a I understand my plans shall be used as public records
:' U
O Licensed Professional
OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
. q O following reason. (Section 703 1.5. Business and Professions Code: Any city or county
m ff which requires a permit to construct, alter, improve, demolish, or repair any StrUCWre
u z >. prior ht its issuance, also requires the applicant for such permit to file a signed statement
- _ < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
e i- m (commencing with Section 7000) of Division 3 of the Businessand Professions Code) or
i .. that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (E500).
❑ 1, as owner of the property, or my employees with wages as their side compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion. the owner-
. builder will have the burden of proving that he did not build or improve for purpose of
sale.).
P�11, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 70". Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
._... ❑_I ex m t under See . B & P C for this reason
Owner c% 4— Date L% "'C.�
W01( 'S COMPENSATION DECLARATION
I hemby affrml uncle penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Camper-
. saiion, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which,this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is Intone hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any mannersp to bcF�rrtc suhiactte the Workcrs' Compensation
Laws of Cali omi „Date U
Applicant "t� „a ”- Lt.- --
NOTICE TO APPLICAI f. after making this Certificate of Exemption, you should
become subject to the W rk rs Compensation provisions of the Labor Code, you must
Z forthwith comply with su h revisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(-+ 1 hereby affirm that there is a coastnrctinn lending agency rot the performance of
(Z > the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lenders Name
Z Lenders Address
U 0 I certify that I have read this application and state that the above information is
tj, — correct- I agree to comply with all city and county ordinances and state laws relating to
O U building construction, and hereby authorise representatives of this city to enter upon the
shove - mentioned property for inspection purposes.
(We) agree to save, indcmni fy and keep harmless the City of Cupertino against
Cn liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
UR REGULATIONS
n
gna urc of Ap rca UCouactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Hcalth and Safety
Code, Section 25532(a)?
E] Yes (pNo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Cali for.
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant that it is my responsibility to noufy the occupant of the
=11 hich t be et prior to Issuance of a Certificate of Occupancy.
r�s� z -,n.7
Owner or autheiri%'d zecnt Date
Job Description
KITCHEN /BATH REMODEL ADD MICROWAVE CIRCUIT, ADD
WASHER /DRYER, ADD A /C -NO FURTHER SANITARY
REQUIREMENTS.
Sq. Ft. Floor Area
36901026 .`` ((V Number
Issued by:
Re -roofs
Type of Roof
Valuation
$150000
Occupancy Type
Required Inspections
Date -3` 2 -_. "--�
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better