07030232 .. ....:..... .. ....... . .. ..... ........ ...
CITE'OF CUPERTINO
BUILDING DIVISIONPERMIT NFOR.lti/�A'T`�EJN
BUIL ING A DRESS: PERMIT NO.
03 0 STEVENS CREEK BLVD TBD — TO BE DETERMINED 07030232
`4R'S NAME: PERMIT ISSUE DATE
IROMETHEUS REAL ESTATE 03/23/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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!00 LICENSED CONTRACTOR'S DECLARATION
V ffi
P I hereby arm that I am licensed under provisions of Chapter 9(commencing Job Description
:z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is UNIT #407 2 0 AMP
? y in full force and of
,No ass * �CROLINE; A/C; HEAT PUMP, WASHER DRYER, HOOKUP,
m wRCHrTEcrS DECLARATION ICE MAKER
W U I understand my plans shall be used as public records
a
o H Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
<$6� which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to 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 Sq.Ft.Floor Area Valuation
t (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or $4200
L r3. 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 Q ,Number Occupancy Type
not more than five hundred dollars(5500). 3 6 9 0 10 2 6 :fd
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered forsale(Sec.7044,Business 'Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of Ll p
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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Ll-
ccnse 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 am exempt under Sec. B&P C for this mason
er Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workees Compen-
sation,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 Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workeess.Compensation n ranee carrier and Policy number are:
Carrier e�lttl e P__1//7iD_PolicyNo.: 713-2Fog-06-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
(—�►-� I hereby affirm that there is a construction lending agency for the performance of
(� the work for which this permit is issued(Sec.3097,Civ.C.)
WKI.A Lender's Name
Z Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
(y .r correct.1 agree to comply with all city and county ordinances and state taws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
CI) ahove-mentioned property for inspection purposes.
Ha (We)agree to save,indemnify and keep harmless the City of Cupertino against
C/1 liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting oV. f is permit.
►" APPLICANT UNDERST S D WILL COMPLY WITH ALL NON-POINT Issued by: Date r— 'Z'
SOUR EGULATIO
17-- -e-roos
Signature of Applicanuton acto Date
HAZARD MATERIALS DISCLOSURE Type of Roof
Will the applicant or fu re building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
dc,Section 25532(a)?
C3 Yes �,No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new mi aerials for inspection.
District?
❑Yes 15CNo
I have read the hazardousmaterialsrequirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a ' at it is my responsibility to notify the occupant of the
rcquir nus which mu e 'or I a Certificate of Occupancy. Signature of Applicant Date
Owner or authorized agent Date
All roof coverings to be Class "B"or better