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CITE' OF CUPERTINO
BUILDING DIVISION PERMIT%
STEVENS CREEK BLVD
OWNER'S NAME:
PROMETHEUS
NE:
ARCHITECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of 'vision 3 of the Business and Professions C , and my license is
in full force and eff Z
License lass Lle• 8
Date Contractor rAee
ARCHITECTS DECLARATIO
1 understand my plans shall be used as public records
Licensed Professional
OWNER- BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any strocture
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
(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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ I, as owner of the property, or my employees with wages as their sale compensation,
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. U,
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 pmject (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 Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
L] 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 ompe! Insurance ca er and Policy number are: f�
Carrier. r�� /i- �i Policy No.:1f -,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars WOO)
or less.)
1 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 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 Codc, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
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 1 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
building construction, and hereby authorize representatives of this city to enter upon the
above - mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of 11j�iirs per tt��
APPLICANT UNDERSTANDSUt�Vt4tL#4RLY WITH ALL NON -POINT
Sign ore of Applicant/Contracttir / Date
HAZARDOUSM ALSDISCLOSURE
Will due applicant or forum boil rag occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cale, Section 25532(a)?
❑ 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?
❑ Yes (� No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building
does not currently have a nan t it is my responsibility to notify the occupant of the
mqui which must a to issuance of a Certificate of.Occup�tt ^.
/!1
Owner or authorized a ni Date
PERMIT NO.
TBD - 'PO BE DETERMINED 07050096
PERMIT ISSUE DATE
SANITARY NO.
20 AMP LINE, A/C AND HEAT I BLDG
f I
rurir, T .0Lr,- 1 ^uyn�n ^tLL41J Job Description
=/;J Ce
Issued by
Re -roofs
Type of Roof
Sq. Ft. Floor Area
APN
Required Inspections
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
Type
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 rr aterials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better
��noF
CUPEKrINO
CITY OF CUPERTINO
PERMIT APPLICATION FORM
c t� 4
()A CCµ::
APN #
X69 - -0 1 .- oZ-6 1,,A 31
Date:
s- �( -,-) -�
Building Address: Mailing Address (if different from building address):
Fee Group
Ow 's Name:
Phone #: "
C" of ,- e
0 --
Co ctor:
2C _ ;� —, Z+D S L��! C
License #:
616 T �
Contact: Phone: g/lv,-y V,3V '
Cupertino Business p se7#:
Fax:
BBOILER2
Building Permit Info: t`,�7 /e � ,, J ,
Bldg ❑ Elect K Plumb 9 Mech
Job Description: fc:�' ON'-\.f2 AC ,-Lt-L, '7-C e /fie C
Residential ❑ OA5k i2iL � c k Commercial ❑ J
Sq.Ft. Floor Area:
Sq.Ft.:
Cost of Project: , f� vu,
Occupancy Group
Y vim,
MECHANICAL
Type of Construction:
Please check this box if the project is a
' i3: 2 CQ
second -story addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
BCONSTAX
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 IM Btu
MECHANICAL
BBOILER4
Boiler > 1M to 1.75 M Btu
MECHANICAL
BBOILER5
Boiler > 1.75M Btu
MECHANICAL
BCONSTAX
Construction Tax
BUILDIlVG
BCONSTAX
Ind/Off/Comm/Quasi
BUILDING
BCONSTAXBQ
Con. Tax for BQ Zone
BUILDIlVG
BCONSTAXH
Hotel and Motel
BUILDING
BCONSTAXR
Constax - Resi/Mobile
BUILDING
BELEC1000
Elec 600V <= 1000A
ELECTRICAL
BELEC1001
Elec 600V > 1000A
ELECTRICAL
BELEC200
Elec Svcs 600V <= 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
1 of 3
I hereby affirm under penalty of perjury one of the following declarations:
❑ f have and will maintain a Certificate of Consent to self -insure for Workers Compcn-
satfon, 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers ompensataypa Insurance carrier e
ier and Policy number a:
Cartier. - /i L" -e Policy No.: �� L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($I00)
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 Workcri Compcnsadon
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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
0
14 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
r>-t the work for which this permit is issued (Sec. 3097, Civ. C.)
Q Lenders Name
Z Lenders Address
Q 1 certify that 1 have read this application and state that the above information is
coreeL I agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorise representatives of this city to enter upon the
W ahovc- mentioned property for inspection purposes.
Gy (We) agree to save, indemnify and keep harmless the City of Cupertino against
r/) liabilities,jodgmcns.coss and expenses which may in any way accrue against said City
Z in consequence of the granting of ns pc
�-+ APPLICANT UNDERSTANDS�WITH ALL NON -POINT Issued by: Date
Re- roofs (/
Sign i.K f pl'.,Contractor Date
HAZARDOUS M ALS DISCLOSURE Type of Roof
Will the applicant or future bull mg 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)?
❑Yes MNo 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 materials for inspection.
District?
❑Yes PNo
I have read the hazardous materials requirements under Chapter 6.95 of the Ca)ifor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
Jos not currently have a coon at it is my responsibility to notify the occupant of the _
rcyw which must a '0 to issuance of a Certificate of.Occu cy.
ts� 1_g/ {_//"_ h Signature of Applicant
Owner or authorized agfnt Q/ " Date
Date
All roof coverings to be Class "B" or better
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
NTtaC
BUILDING ADDRESS:
PERMIT NO.
20380 STEVENS CREEK BLVD
TBD - TO BE DETERMINED
07050096
OWNER'S NAME:
PERMIT ISSUE DATE
PROMETHEUS RE GROUP
PHONE:
SANITARY NO. CONTROL NO.
A RCHITECT/ENGI NEER:
BUILDING PERMIT INFO
20 AMP LINE, A/C AND HEAT
BLDG ELECT PLUMB MECH
Z
LICENSED CONTRACTOR'S DECLARATION
r
Job Description
F
c.
I hereby affirm that I am licensed under provisions or Chapter 9 (commencing
with Section 7000) of vision 3 of the Business and Professions Co}�e, and my license is
in full force and effe �"� i 4 Z f
_ _.-,
ZLicense
o
Class `•� " - Lic. p f ( V C�
Dam Contractor '• C--
"
..f =,�Li C,
1
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
U
H
Licensed Professional
OWNER - BUILDER DECLARATION
. �
I hcrchy affirm that I am exempt from the Contractor's License Law for the
,0
following rason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to ennsuuct, alter• improve, demolish, or repair any structure
prior to its issuance, also requires the applicant forsueh permit to file a signed statement
he is licensed the of the Contractors License Law (Chapter9
Sq. Ft. Floor Area Valuation
$
. ,
that pursuant to provisions
(commencing with Section 70DO) 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 (5500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
fl
will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business
Contractor's License Law does not apply to an owner of
and Professions Code: The Contractor
9 p
property who builds or improves thereon, and who does such work himself or though 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, use 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 Conuactors 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 Contractors
License Law.
❑ I am exempt under Sec . B & P C for this reason
Owner Dane
WORKERS COMPENSATION DECLAFAT70N
I hereby affirm under penalty of perjury one of the following declarations:
❑ f have and will maintain a Certificate of Consent to self -insure for Workers Compcn-
satfon, 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers ompensataypa Insurance carrier e
ier and Policy number a:
Cartier. - /i L" -e Policy No.: �� L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($I00)
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 Workcri Compcnsadon
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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
0
14 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
r>-t the work for which this permit is issued (Sec. 3097, Civ. C.)
Q Lenders Name
Z Lenders Address
Q 1 certify that 1 have read this application and state that the above information is
coreeL I agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorise representatives of this city to enter upon the
W ahovc- mentioned property for inspection purposes.
Gy (We) agree to save, indemnify and keep harmless the City of Cupertino against
r/) liabilities,jodgmcns.coss and expenses which may in any way accrue against said City
Z in consequence of the granting of ns pc
�-+ APPLICANT UNDERSTANDS�WITH ALL NON -POINT Issued by: Date
Re- roofs (/
Sign i.K f pl'.,Contractor Date
HAZARDOUS M ALS DISCLOSURE Type of Roof
Will the applicant or future bull mg 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)?
❑Yes MNo 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 materials for inspection.
District?
❑Yes PNo
I have read the hazardous materials requirements under Chapter 6.95 of the Ca)ifor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
Jos not currently have a coon at it is my responsibility to notify the occupant of the _
rcyw which must a '0 to issuance of a Certificate of.Occu cy.
ts� 1_g/ {_//"_ h Signature of Applicant
Owner or authorized agfnt Q/ " Date
Date
All roof coverings to be Class "B" or better