07100209 CITY OF CUPERTINO ' ' �
BUILDING DIVISION PERMIT �����"��� ���������� '
�: _: , : :.:, ..... .
_.
PERMIT NO.
BU(LD � v � n �4� ss �ALIFORNIA OAK WAY BOTHWEL:� CONSTRUCTION CORP. 07100209 .
PERMIT LSSLIE DATE
JER'S NAME:
PG&E 1590 IN:�USTRIAL AVE � 10/30/2007
SANITARY NO. CONTROL NO.
PHONE:
(408) 2�8-8049
. BUI[.DING PERMIT INFO
ARCHITECC/ENGiNEER:
BLIX; ELECT PLUMB MECH
a o 0 0
i p � LICENSED CON7RAGTOR'S DECLARATION IOb DeSCflptlOfl
i V� 1 hcrcby aCfirm �hat I am licenscd unckr provisions aC Chaptcr 9(commcncing
; z� wi�h Scction 7000) of Division 3 of ihc Business and Profcssions Code and my Iicense is T E L E C OM �IUN I C AT I ON FAC I L I TY
�� y in lull force and cffect � ( 5
� v� Z Licensc Class /3 Lic. �
. E „ � Da�c /r� --3o•—a'7 Conuactor �
ARCHITECTS DECLARATIO
i� Q 1 undcrstand my plans shall bc uscd as public rcconis
1yU
° u. y Licenscd Pmfcssional
' � < OWNBR-BUILDER DECLARA'CION
j a� 1 hcrchy a17rm that 1 am excmpt (rum thc Conuaccofs Liccnsc l.aw for ihc
. p O (ollowing mason. (Section 7031.5, Busincss and Profcccions Codc: Any city ar mumy
�°„ � which rcquires a pertnic to conswc4 ��r, improvc, dcmolish, or repair any suuctucc
? Z} prior ui i�s issuance, also requires the applicant Cor such pertnit to file a signed s�amment �, Ft. Floor Area Valuation
�_ � �hat hc is liccnscd pursuant to thc provisions of thc ConUacwr's Liccnsc Law (Chap�cr 9 � 5 0 O O
u F- �(commencing with Scction 7000) of Division 3 0( thc Busincss and Profcssions Cadc) ur
,, �.. that he is ezempt thcmfrom and the basis Cor the allegcd ezempdon. Any violation of
Section 7031.5 by airy applicant fo� a pertnit subjecu U�e applicant �o a civil penalty o( 3 4 2 6 3 0 01A� Number Oeeupaney Type
not more than fivc hundred dallars (5500).
❑ I, as owncr of tl�e property, or my cmployca with wages u the'v solc compensation,
will do the worlc, and the suuctum is not inter.dcd or cllered for sale (Sec.7044. Business Required Inspections
and Professions Code: The Conuactor's License Law daes not apply to sn ownec of
propeny who builds or improves thereon, and who does such �xork himselt or thtoagh his
own employecs, provided that such improvements are not imm�ded or o((ered Cor sak. IC,
however, the building or improvemenl is sold within one year of comptction, d�e owner-
builder will have the burden of proving that hc did not build ar improvc (or pmpose of
salc.).
❑ I, as awner of the property, am eacclusively conuacting wi�h licensed rnnuxtors to
construct the pmject (Sec. 7044. Busincss and Professions Cade:) The Conuaanrs Li-
cense Law docs not apply w an owner of propeny who builds or impmvrs the�eon, and ,
who contracts for such projects wi�h a contractor(s) licensed pursuant w the Convxto�s
r ;cense Law.
am exempt undu See , B& P C for tdis reason
„wner Da�e _ .
WORKER'S COMPENSA'i'[ON DECLARAT[ON
I hercby afficm under penalty of perjury one af �he following declarations:
❑ I hsre and will maintain a Certificate of Consent to self-insurc for Workcrs Camprn-
sation, as providcd for hy Section 3700 of the Iabor Code, for thc performarax oC thc
work for which ihis permit is issucd.
0 I havc and will maintain Workcr's Compensation Insurance, u�cquired by Scction .
3700 of �hc Labar Codc, Cor thc performance of the work for w6ich �his pecmit is issued.
My Worker's Campensadon Insucance carticr and Poliry numbcr are:
Cartier. 5 7Y.Ye- t+ Policy No.: ]� 3 o E LG � t 3
CER7'I CATE OF EXEMPI70N FROM WORKERS'
COMPENSATION INSURANCE
('Chis sectian necd not 6c completcd i(the permit is fwonc hundred dollus (5100)
ar Icss.)
I cenity that in ihc performancc af thc work (or which Uiis permit is issucQ I shall na
omploy any person in any manner so u to bccomc subject to the Workcrs' CompensaGoa
Laws of California. Datc
Applicant
NOTICE TO APPCICANT: If, aficr making ihis Certificate of Ezcmptian, yau should
bccome subjcct to thc Workcr's Compcnsation provisions o( thc Lal+or Codc, yau muu
� O forlhwiih comply with such provisions or this permit shall bc dccmcd ccvokcd.
z "'" CONSCRUCf10N LENDING AGENCY
(� �-�. 1 herchy affirm that thcre is a consuucuan Icnding agcncy Cor thc perCormanoe o! -
p�., � ihc work for which this permit is issucd (Scc. 309'1, Civ. C.1
W Q Lendcr's Namc
� z Lender's Address
V � I certify Ihat 1 have rcad Ihis applieation and sta�e Ihat the above in[ortnauun is
w � cortcct. I agrce w comply with all ci�y and county onlinances and siate Iaws relating m
0 U 6uilding conswction, and hcrcby au�hori�e represcntativcs of this ci�y to cn�er upan �hc
� a alwvrmcntioncd property (or inspccuon purposes.
(Wc) agree to save, indcm�ify and kccp hartnless ihc City of Cupenino against
r ,H„� � IiabiliUes, judgments, cos�s and expenses which may in any way acerue agains� said City
(„) ,Z in consequencc of the granting of ihis permit. Date
� APPLICA DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE G ATIONS. .
- �-� Re-roofs
Signuum of App icanUConuac �� T e of R�of
HAZAR� MATERIALS DISCLOSURE yP
�11 �hc applicant or building occupant storc or handlc harardous matcrial
�cfined by 1hc Cupertino Municipal Codc. Chaptcr 9.12, and �hc Hcatth and SaCcly
,.ode, Sccuon 25532(a)? All roofs :,hall be inspected prior to any roofing material being installed.
aY� �e� .
Will the applicant or futurc building accupant usc equipmcnl or dcvices which
If a roof i:, installed without first obtaining an inspection, I agree to remove
emit harardous air coniaminants az Jcfincd by the Bay Arca Air Quality Managcmcnt all new m�terials for inspecr,ion.
Disirict? �
❑ Ycs
I havc read ihe haiardous ma�crials requircmcn�s undcrChap�cr6.95 of thc Califar-
nia Hcalth & Satcry Codc, Scctions 25505.25533 and 25534.1 uncicrs�nd �hu iCihe Gu►diaS
docs �ot curtently a tcnant, iha� it is my rcsponsibiliry to nodfy Uu oocupant o( �hc
reyuircmcn�s wh� m 6c me! pri � uancc of a Ccnificaie of Occupancy. Signature of Applicant Date
- - d All roof coverings to be Class "B" or better
Owncr or authori•r.cd agcn� Datc —