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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILRtrr,G�apl�(ITEVENS CREEK BLVD ABLE MAINTENANCE PERMIT 08040195
OWNER'S NAME: PERMIT ISSUE DATE
SHELL OIL PRODUCTS US 3224 REGIONAL PKWY 07/14/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: INSTALL VAPOR RECOVERY BLDG BUILDING PERCrrPLUMB
MECH
0 0 0 0
!00 LICENSED CON'TRACTOR'S DECLARATIONIOb Description
v 1 hereby affirm Nat 1 am licensed under provisions or Chapter 9(commencing ------
Z with Section 7000)of Division 3 of the Business and Professions Code,and my licenseis
=y in full farce a eff G10 /aAZ. 3�ZBi
j v�z License Cl Lie.N
;Fp Date Y- ContractorAMC /a'tAAlTFNf4NCE
ARCHITECTS DECLARATION
a 1 understand my plans shall be used as public records
)yU
a t Licensed Professional
S ag OWNER-BUILDER DECLARATION
a1 hereby affirm that I am exempt from the Contractor's License law for the
`
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
m Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
a Z prior to its issuance,also requires the applicant for such permit to rale a signed statement
a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
uF$ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
L 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 more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compensadon,
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 dares not apply to an owner of Required Inspections
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 Contractors U.
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 Sec ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of pedury one or the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for WorlrefsCompen-
sation,as provided for by Section 3700 of the labor Code,for the performance or 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 Workfees Compensation Insurance carrier and Policy number are:
Carrier. -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)
1 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.Dare
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workces Compcnsatian provisions or dee labor Code,you must
O forthwith comply with such provisions or this per=il shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
�+►�.a 1 hereby affirm that there is a consuuction lending agency for dee performance of
'.Yo' > thework for which this permit is issued(Sec.3097,Civ.C.) '
:C)Q Lenders Name
Trader's Address
J 0 1 certify that I have read this application and state that the above information is
.i. at.".,' correct.1 agree to comply with all city and county ordinances and state laws relating to
p building construction,and hereby authorize representatives of this city to enter upon the
a shave-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
cn liabilities,judgments.costs and expenses which may in any way accrue against said City
J Z in consequence of the granting of this permit.
APPLIQANT UN ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU GU NS.
2-1'q-00 Re-roofs
Si of Applicant/Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupantstom or handle hazardous material
as defined by the Cupertino Municipal Code,Chaptcr 9.12,and the Health and Safety
Cade.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
Will the applicant or future build' atcupanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as d by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea o
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Codc. 'ons 25505,25533 and 25534.1 understand d at if ile building
does not c y have ant.that it is my responsibility to notify the occupant of the
require= h et priorto issuance of a Certificate of Occupancy. Signature Of Applicant Date
(4.03
owner a athorixed agent ACEtrr �M A1tL.B Dato Al] roof coverings to be Class l or better
NO Ll v � q5
F CITY OF CUPERTINO >
C1T'1'OF
CUPERI-ANO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# � CDate:c� c�
Building Address:
19 9 9 o e)-Tt�ve7,4
Mailing Address (if different from building address):
Owner's Name: Phone#:
54E , OIL V �p (: lW)
Contractor: Phone: 70 7- 54 5 „ ear) Z Z
MuC Fax: 767-- 515 - 551
Contractor License #: t4 It
Cupertino Business License #: 2- 13 q Lf
Contact: ZAI&A & ('A Q I N 0 _ �j-f - Phone: 7p 7 - 76r2_ r'�(a D
Fax: 7,6'7 - 76 S ' g 9 0 g,
Residential ❑ Commercial
Job Description: NGj j i� ll'�V Q �4)O'N(.C-'CJ
Is the project in the Wildland-Urban Interface Fire Area? Yes ❑ No ❑
Building Permit Info:
Bldg Eleci ❑ Plumb, ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 11-B ❑ 11, 111, V-A ❑ 11, 111, 1V V-B
Valuation: [Cgoa UO Square Footage:
Project Size: Standard L4�Lar e ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at w-Nvvv,buildit jreen.or '0—