08060169BUILDING DIVISION PERMIT
z
z
�;
:L) A
�z
JO
H
�U
11114
tt-n 10AI
W
RD BLDG 69 I WEST BUILDERS, INC.
OWNER'S NAME:
PROMETHEUS
ARCHITECTIENGINEER:
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
n full farce and effect
L
Die
ate ContractorC8CrS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
fallowing mason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to wnstruc4 alter, improve, demolish, or repair any structure
prior to its issuance, aiso requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License taw (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 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500),
❑ 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
and Professions Code: The Contractors 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.).
❑ 1, 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 reason
Owner Date
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 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.
❑ I 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:
Caner. �c`� 1 S Policy No..
CERTIFICATE OF EXEMPTION PROMM 0
COMPENSATION INSURANCE
('rids section need not be completed it the permit Is fierane hundred dollars ($I00)
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 mannerso 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 invoked.
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
Landers Address
I certify that I have read this application and state that the above information is
conecL 1 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 grandn of this permit.
APPLICANT UNDERSTA ND WILL COMPLY WITH LL NON -POINT
SOURCE L ON
d ( D
57
Signature of t/ t Date
H OUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)?
❑Yes o
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
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor.
niaHealth &SafclyCode, Sections 25505,25533and 25534,1understand that ifthe building
does not currently have a tenant, that it is my responsibility to notify the upant of the
require is whin t t prior to issuance of a rti0cate Occup
b a
Owner onzc ae n Date '
1608 4TH ST STE 120
PERMIT NO.
08060169
PERMIT ISSUE DATE
07/18/2008
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
INSTL TEMP WTR SUPLY&RETRN BL�DG ELECTPLUMB
P I Rib , ±NSIFfi Pf NEW
Job Description
Sq.
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy
Date
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 materials for inspection.
Signature of Applicant Date
. All roof coverings to be Class "..' or better