08060217MY OF CUPERfINU
BUILDING DIVISION PERMIT
RD BLDG 6 1 WEST BUILDERS, INC.
OWNER'S NAME:
PROMETHEUS
ARCHITECT/ENGINEER:
i Ad p p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Secdon 7000) of Division 3 of the Business and Professions Code, and my license is
' y in full force and effect lt s^
j Z License Cl as Lic. N v
t O Datc Contractor lrti < S3
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
54
D. Licensed Professional
40 OWNER -BUILDER DECLARATION
a1 hereby affirm that I am exempt from the Contractor's License Law for the
cc 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 for such permit to file a signed statement
T O that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
ut- $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
Le .. 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 ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
'own employees, provided that such improvements am not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves themon, and ,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sea B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3100 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit Is issued.
My Worker's Compensation Insurance carrier and Policy number armc�:
Carrier V—UN� Policy No :rZ�Z,.
CERTIFICATE OF EXEMPTION FROM -WORKERS'
COMPENSATION INSURANCE
(MIS section need not be completed if the permit is foronc hundred dollars ($I00)
or less)
1 cerifv 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. 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
)— CONSTRUCTION LENDING AGENCY
b I hereby affirm that there is a constructinn lending agency for the performance of
Ya' the work for which this permit is issued (Sec. 3097, Civ. C.)
ALender's Name -----
jZ Lenders Address
J 0 1 cenify that I have read this application and state that the above information is
yr Ecorrect. I agree to comply with all city and county ordinances and state laws relating to
V 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
rrA liabilities,judgments, costs and expenses which may In any way accrue against said City
in consequence of the granting of this permit.
r--II APPLICANT UNDERST D ND WILL COMPLY WITH ALL NON -POINT
S REGU ON
p7 U
Si at o cantlC n ctor Date
HA4ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building 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 s( No
Will the applicant or future building occupant use equipment or devices which
cmlt hazardous air contaminants as dermcd by the Bay Area Air Quality Management
District?
❑Yes Mrvo
l have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenan4 that It is my responsibility to notify, the occupant of the
mquirem ,which sJr to issuaCnVfrt�pancy.
ownerorh�ae nt Date e. .
1608 4TH ST STE 120
PERMIT NO.
08060217
PERMIT ISSUE DATE
07/18/2008
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
INSTL TEMP WTR SPLY& RETRN BLDG ELECT PLUMB
Job Description
Sq. Ft. Floor Area
um
Issued by:
Re -roofs
Type of Roof
Required Inspections
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'n" or better