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CITY OF CUPEKIAj O "J
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING AD ESS:
203 0 STEVENS CREEK BLVD TBD - r10 BE DETERMINED 07050099
OWNER'S NAME: PERMIT ISSUE DATE
PROMETHEUS RE GROUP
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
20 AMP LINE, A/C AND HEAT BLDG ELECT PLUMB bfECH
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code. and my license is
in full
xoCTS DECLARAnoN
I understand my plans shall be used as public records
Licensed Professional
OWNER - BUILDER DECLARATION
1 hereby allirm that 1 am exempt from the Contractor's 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 structure
prior to its issuance, also requires the applicant rot 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 ($500).
0 1, 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
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 arc 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.).
0 I, as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Coutractors In-
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.
0 1 am exempt under Sea B & P C for this reason
Owner LADate
WORKER'S COMPENSATION DECRATION
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I hereby affirm under penalty of perjury one of the following declarations:
1] I have and will maintain a Certificate of Consent to self -insure for Workers 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 I have and will maintain Workers Compensation Insurance, as required by Section
1700 of the Labor Code, for the performance of the work for which this permit is issued.
Ay Workers Compensation Insurance carrier and Policy nl comber are:
:artier eT� �- L'fwb/ Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
)r less.)
i certify that in the performance of the work for which this permit is issued, 1 shall not
:mploy 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.
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
I 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
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 this emit.
APPLICANT UNDERST ND N WILL COMPLY WITH ALL NON -POINT
SOURC llL,ATION
Signature of Applicant/Co Store Date
HAZA61di�ng�=Upant. ALSDISCLOSURE
Will the applicant or store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)?
0 Yes fNo
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?
0 Yes INo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 2550 d 25534.1 understand that if the building
does not currently have a ten t, th �mponsibility to notify the occupant of the
require wh st be t ortificatc of Octupa�tcy, O
Date
Job Description
Z;113(C
;q. Ft. Floor Area
Required Inspections
Ig
Issued by:
Re -roofs
Type of R Hof
Valuation
Occupancy Type
Date
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
all new m 3terials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
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CITY of
CUPEkTINO
CITY OF CUPERTINO QP,
PERMIT APPLICATION FORM b�7 L 1 o 1
APN # Date:
Building Address: address):
sss: ailing Address (if different from
Addr �d L_ " :' k Vb�ilding
O 's Name. P
Phone #:
Co actor:
License #:
I
-S ? S Z
MECHANICAL
I
Contact: �, Phone: yeqp �/' 6�3
®
Cupertino Business License #:
CL / / o Fax: 3 � S3i
Building Permit Info:
Bldg ❑ Elect P-__ Plumb 01" Mech
Job Description: W-ee
Residential ❑ 1 r45&,erZ Commercial ❑
Sq.Ft. Floor Area:
Sq.Ft.:
Cost of Project: lvz
Occupancy Groin
Type of Construction,
Please check this box if the project is a
5Pi2 vX (L_ Q
second-story addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
Boiler > 1.75M Btu
Quanti
Fee ID
Fee Descri tion
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
BELEC 1000
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
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO,
203.8' STEVENS CREEK BLVD
TBD - TO BE DETERMINED
07050099
OWNER'S NAME:
PERMIT ISSUE DATE
PROMETHEUS RE GROUP
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
20 AMP LINE, A/C AND HEAT
BLDG ELECT PLUMB MECH
-1 0 0 0
LICENSED CONTRACTOR'S DECLARATION'
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
- -- ---- --.. -. -. --- ----� - -.-. -... .... -,
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and cff,
License ass Lie. p
Date — Contractor,%c:. --��
ARCHITECTS DECLARATION
I understand my plans shall be used as public recofd.s
Licensed Pmfcssional
OWNER - BUILDER DECLARATION
I hcrchy affirm that I am exempt from the Contractors License Law for (he
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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(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 (5500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
ns
Required Inspections
q
will do the work, and the structure is not intended or offered for sale (Sec. 70". Business
and Professions Code: The Contractor s License Law does not apply to an owner of
P
property who builds or improves thereon, and who does such work himself or through his
own employers, provided that such improvements are not intended oroffered 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 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 Contractors
License Law.
❑ 1 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:
❑ 1 have and will maintain a Certifrcatr of Consent to self- insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
p 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 Worker's Compensation Insurance carrier and Policy n�ttu/ber are:
Carver. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhis section need not be completed if the permit is for one hundred dollars (5100)
or Icss-)
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 Lahor Code you most
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I botchy 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 Namc
,
Lenders 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 state laws relating to
building construction, and hereby authorne 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
Iiabiiitics,judgmems, toss and expenses which may in any way accrue against said City
in consequence of the granting of Ihis crmit.
APPLICANT UNDERST ND N WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR EGULATION
6W-C-3
c-
Re -roofs
Type
Signature of Applicant/Co era or Date
HAZARDOU ATERIALS DISCLOSURE
of Roof
Will the applicant or future uilding occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code. Stxtion25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes f]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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes x u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Code, Sections 25505 d 25534.1 understand that if the building
dots not currently have a ten t th t a m ponsibility to notify the occupant of the
rcyuirc '1h mustM t onto oGcatcofa ancy.
�.
Signature of Applicant Date
All roof coverings to be Class "B" or better
ON authorized agcnl Datc