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07050098I to Vp i<a - =2 AFC 7C� � A. - U. 9y� 2 < °m °z> ESC ir3°5- 0 'e Z , U H � �i W�Q, a� UC wE (~ r rti G U ;r CITY OF CUPERTINO DIVISION PERMIT�R T' BUILDING BUILD D RESS: PERMIT NO. �N �� 0 STEVENS CREEK BLVD TBD — TO BE DETERMINED 07050098 OWNER'S NAME: PERMrf ISSUE DATE PROMETHEUS RE GROUP 7 NE: SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO 20 AMP LINE, A/C AND HEAT BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION feE Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing - •� -- -- - -- - -- _ - - -- -- with Section 7000) of Division 3 of the Business and Professions Codc, and my license is in full force and L License CI Lic. # Dae / Contractor C. -+ r. ARCHITECT'S DECLARA ION I understand my plans shall be used as public records Licensed Professional OWNER - BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 703 1.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve. demolish, or repair any structure prior to its issuance. also requires the applicant for such permit to file a signed statement Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). 0 I, as owner of the property, or my employees with wages as their sole compensation, Required Inspections q P 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.). ❑ 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 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. ❑ 1 am exempt under See . B & P C for this reason Owner Dale 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 Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 0 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 Worke Compensa ' a Insurance cart. and Policy n her am: �l C J�-� �� U fizzier. t�[si✓Poliry No.: /� O CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one 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 manner so as to become subject to the Workers' Compensation Laws of California. 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 forthwith comply with such provisions or this permit shall be deemed revoked. i { 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.) Lender's Name Lender's Address 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and stale laws relating to " building construction, and hereby authorize representatives of this city to enter upon the above- mentioned property for inspection purposes. (We) agree to save, indcmoify and keep harmless the City of Cupertino against j liabilities, judgments, costs and expenses which may in any way accrue against said City r in consequence of the granting of this permit. " APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOU REGULDTI S ^ '© '1 Re -roofs Type of Roof Signature of ApplicaniXonuractopV4 Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupantstorc or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑Yes X No All roofs :;hall be inspected prior to any roofing material being installed. If a roof i;; installed without first obtaining an inspection, I agree to remove 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 all new materials for inspection. District? DYes No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safcty Cade, Sections 25505, 25533 and 25534.1 understand that if the building does not currcn I have a ten 4 that it is my responsibility to notify the occupant of the rcyui is which must be a issnan f a Certificate of Oc+upagcy � Signature of Applicant Date "B" All roof coverings to be Class or better authorized pam Owncrorautho CUPEkTINO CITE' OF CUPERTINO PERMIT APPLICATION FORM "At-v, -� APN # - - 0 1--, 1-.:.4 Date: 1(- Building Address: Mailing Address (if different from building address): Ow 's Name: ,, /I Phone #.: Co ctor: �i Q-C , S ; C, C �- License #: his- ?& z Contact: Phone: -'Ic)e �' 6�." C L /Ij/1 v Fax: Cupertino Business License #: Building Permit Info: . ( e- (y A4 Bld - Elect Plumb Mech a Job Description: Ai-,LP rA ; C/Lc : G j •� �� �- F- �.,,�� , -e %-'Lfl-A- C� Residential ❑ r,,1 i, '�(� 22 -0 1 L, Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: , ` U Occupancy Group Type of Construction ii Please check this box if the project is a second-story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ Boiler > 500K to 1M Btu Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax - Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 (Phis section need not he completed if the permit is for one hundred dollars ($ 100) or less.) I certify Net 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 Workeri 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 Z forthwith comply with such provisions or this permit shall be deemed revoked. 0 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.) QL.endces Name 2 Lender's Address 0 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to U building construction, and hereby authorise representatives of this city to enter upon thc W above -mcntwned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against vi liabilities, judgments, costs and expenses which may in any way accrue against said City I Z in consequence of the granting of this perrttiL APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON -POINT SOUR REGULA77 S - 'M Signature of ApplicanU ontiacto 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 Health and Safety Code, Section 25532(a)7 ❑ Yes No 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? El Yes No I have rcad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code. Sections 25505. Z5533 and 25534 .1undcrsand that ifthe building does not cu (I have a ten L Nat it is my responsibility to notify the occupant of the rcyunr ts which mttst be a rssuan f a Certificate of Occupy ,ice S - '(�� Owner or authorbrd Date Issued by: Re -roofs Type of Roof Date 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 CITY OF CUPERTINO c� I eTO NF.., aMa ro ", BUILDING DIVISION PERMIT BUILD�N8180ESSTEVENS PERMIT NO. CREEK BLVD TBD - TO BE DETERMINED 07050098 OWNER'S NAME: PERMIT ISSUE DATE PROMETHEUS RE GROUP 05/11/2007 PHONE: SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO 20 AMP LINE, A/C AND HEAT BLDG ELECT PLUMB MECH Z g LICENSED CONTRACTOR'S DECLARATION Description 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing ---job U with Section 70(10) of Division 3 of the Business and Professions Code, and my license is G in full force and tom- I' J Lic. ❑ Liccnsc Class N Date r Contractor 0 ARCHITECTS DECLARA ION I understand my plans shall be used as public records, �- LianscJ Pmfcssional a OWNER-BUILDER DECLARATION � I hereby alErm that I am exempt from the Contractor's License Law for the O following ason. (Section 7031.5, Business and Professions Code: Any city or county rZ which requires a permit to construct. alter, improve, demolish, or mpair any structure y prior to its issuance, also rcquires the applicant for such permit sortie a signed statement Sq. Ft. Floor Area Valuation < that he is licensed pursuant to thc provisions of thc Contractor's Liccnsc Law (Chaptcr9 ❑ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (1500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, -Required Ins ectlo ns P will do the work, and the structure is not intended or offered forsale (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.). ❑ 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 Li- cense Law does not apply to an owner of property who builds or improves thereon, and . who contracts for such projects with a contractors) licensed pursuant to the Contractors License Law. ❑ I am exempt under Sec . B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: - ❑ I have and will maintain a Certificate of Consent to self -insurc for Workcfs Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the wort: for which this permit is issued. ❑ 1 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 Worker 'CCom�pensai�n Inssu�rance e carrier and Polity n bcr are` Carrier. n t/ ! `_C'/ Policy No.: l i� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Phis section need not he completed if the permit is for one hundred dollars ($ 100) or less.) I certify Net 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 Workeri 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 Z forthwith comply with such provisions or this permit shall be deemed revoked. 0 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.) QL.endces Name 2 Lender's Address 0 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to U building construction, and hereby authorise representatives of this city to enter upon thc W above -mcntwned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against vi liabilities, judgments, costs and expenses which may in any way accrue against said City I Z in consequence of the granting of this perrttiL APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON -POINT SOUR REGULA77 S - 'M Signature of ApplicanU ontiacto 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 Health and Safety Code, Section 25532(a)7 ❑ Yes No 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? El Yes No I have rcad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code. Sections 25505. Z5533 and 25534 .1undcrsand that ifthe building does not cu (I have a ten L Nat it is my responsibility to notify the occupant of the rcyunr ts which mttst be a rssuan f a Certificate of Occupy ,ice S - '(�� Owner or authorbrd Date Issued by: Re -roofs Type of Roof Date 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 Jun Iy U/ U4:J3 Jp 4U8-463-8331 4084638331 p.2 - • . . - - -- vim. . ... '.I I U I(n0011002 C.- Mmuniity DeveIopni= 10300 Torre Avenue Cupertino CA 95014 Tcd�one (408)777 -3228 Fir (408) 777 -3333 Building Department JOB ADDRESS- y�f PER # c ^ / II�IPT OWNER'S NAME: l PHONE # _- GENERA>L. CONTRACTOR PAX # I am not using any subcontracto : / Signs Date Please check aprpUcable subcontractors and complete tffe foHowing information: WKWA 0[f4aVte 7-- SUBCONTRACTOR BUSINESS NAME BUSMESS LICENSE I Cabinets & Millwork Cement Finishing - .1ectrical - Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing _ Heating Ir+sulation - Landscaping Lathing -_ Masonry Ornamental Sheet Metal _ Painting / Wallpaper Paving Plastering - Plumbing Roofing Septic Tank Sheet Metal Sheet Rock zee Je L WKWA 0[f4aVte 7-- Jun 19 07 04:40p 408 - 463 -8331 4084638331 p.1 10002/002 C.jmmunity Development 10300 Torre Aveaue Cuperdno CA 95014 T:li -phone (408) 777.3228 Fax (409) 777 -3333 Buildine Department JOE ADDRESS: _203 So , v C / v FERWr # 7G�{ OWNER'S NAME: , PHONE # GENERAL CONTRACTOR- AX # r G 109 I am not using any subcontractor Signa 171Paea r}�Pr -k annlicahie s�hcontrartnrs and mmnlpte P ollowinw inforr atior: qDate (V7 oilrafor Signature OlPCl5lbil TMdv5j JWC., F977, ir SUBCOM RACTOR BUSINESS NAME BUSYNFs.)S LICENSE # Cabinets & Millwork Cement Finishing _ Electrical Excavation _ Fencing Flooring: SHEeting -- Linoleum / Wood -- Glass / Glazing - Heating Insulation Landscaping - Lathing - Mwonry Ornamental Sheet Metal Fainting / Wallpaper Paving Plastering Plumbing Roofing _ c Tank Sheet MetaI Sheet Rock Tile -- oilrafor Signature OlPCl5lbil TMdv5j JWC., F977, ir