09060016 CITY OF CUPERTINO
BUILDING DIVISION PERMIT G�1 ('TR� CfR I� I�MTI�1�1'
PERMIT NO.
BUILDING ADDRESS:
20350 STEVENS CREEK BLVD #402 ORION F-MNCIAL SERVICES 09060016
PERMIT ISSUE DATE
OWNER's NAME:
PR(D ,ry,PJ1E1J2 REA1 >♦STATE GAGTdP
A R CONTROL NO.
ONE:
(916) 789-8484
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
0 0 o a
a 00 LICENSED CONTRACTOR'S DECLARATION Job Description
v I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3ofthe Business andProfessionsCode,andmylicenseis WASHR&DItYR RETRFFS KTCHN&BTH CABNT& COUNTR-TOP
H in full force and effect.
; z License Class Lic.# UPGRDI D17CTLS SPLIT SYS;HVAC RETROFT
=^ctDate Contractor
n h+ ARCHITECTS DECLARATION
-� I understand my plans shall be used as public records
�yU
y O y Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
E p O following mason.(Section 7031.5,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 Valuation
P Ft.Floor Area
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
(commencing with Section 7000)of Division 3 of the Business and Professions Cade)or $3900
y 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 APN Number Occupancy Type
not mote than five hundred dollars($500). 3690102L .402
❑I,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 for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conuactor'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.).
❑I.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.
❑I am exempt under Sea B&P C for this mason
Owner Dale
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-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.
❑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's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
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 Worke's Compensation provisions of the Labor Code,you must
,J Q forthwith comply with such provisions or this permit shall be deemed revoked.
z h 4 CONSTRUCTION LENDING AGENCY
[~-r rA I hereby affirm that there is a construction lending agency for the performance of
�.h:+ the work for which this permit is issued(See.3097,Civ.C.)
W Q Lender's Name
�z Lender's Address
U 0 I certify that I have read this application and state that the above information is
LL 0"' cortccL 1 agree to comply with all city and county ordinances and state laws relating to
0 V building convection,and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
rn liabilities,judgments•costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b'r:
SOURCE REGULATIONS.
Re-roofs
Cl-
Signature of Applicant/Conuaclor Dare
HAZARDOUS MATERIALS DISCLOSURE Type of'.Zoof
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)? All roof. shall be inspected prior to any roofing material being installed.
C]Yes ❑No
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
ML hazardous air contaminants as defined by the Bay Area Air Quality Management all new I naterials for inspection.
Jisvict?
❑Yes ❑No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy. Signatur.'of Applicant Date
All roof coverings to be Class'A"or better
Owner or authorized agent Date
090("oo
CITY OF CUPERTINO BUILDING I3ERMIT APPLICATION
E-Mail ORION ED-SUREWEST.NET
Jobsite Address: 20350 STEVENS CREEK BLVD Date: 1/7/09
APT 402
Owner's Name:PROMETHEUS REAL ESTATE GROUP
Phone No.:(408 25) 3-7100
APN#: 369-01-NO Project Valuation: $3900.00
Blg. Permit Information: Bldg. ■ Elec.■ Plumb.■ Mech.■
JOB DESCRIPTION
Washer and Dryer Retrofits; Kit,;hen and Bath cabinet and counter-
top upgrade. Ductless split systom;HVAC Retrofit.
CONTRACTOR INFORMATION
Company:ORION DEVELOPMENT Phone:(916) 789-8484
Contact Name: STEVE WHITESIDES Fax:(916) 789-1051
Address: P.O. BOX 693
City, State, and Zip:Roseville. CA 95678
State Contractors License: 747992 Exp. Date:9-30-2009
Worker's Comp.# : 238-0002445-07 Carrier:STATE FUND Exp. Date: 4-1-2010
Cupertino Business License#:
CREDIT CARD INFORMATION
Credit Card#: 4246 3151 4062 7744
Name on Card: Orion Financial Services In,.,.
Expiration Date: 01/10
Visa 0 MasterCard 0 Discover 0 American Express C]