07080270CITY OF CUPERTINO TaT��TJLi
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BUILDING DIVISION PELVT
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PERMIT NO.
lJ CREEK BLVD UNIT
PRECISION TRADES INC.
07080270
OW AME:
PERMIT L95UE DATE
PROMETHEUS REAL ESTATE
615 PALM AVE
08 3 2 7
PHONE:
SANITARY NO. CONTROL NO.
(408) 463-9300
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed undo provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
20 AMP MICRO LINE , A / C HEAT PRIMP, WASH DRYER
in full farce and effort
License Class �• °
HOCKUP ICE MAKER
Date Contractor
,
ARCHIIEC'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alTirm that I 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 sutecturc
prior to its issuance, also requires the applicant for such permit to file a signed statement
is licensed to the of the Conractor's License Law (Chapter9
Sq. Ft. Floor Area
Valuation
that he pursuant provisions
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 4 2 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number
Occupancy Type
Sutton 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
not more than five hundred dollars ($500).
3 6 9 010 2 6 .``)t
❑ 1, u owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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 himaeif or through his
own employees, provided that such improvements are not intended oroRered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will havelhe 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 Coauaetoes 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 Dale
WORKERS COMPENSATION DECLARAMON
I hereby affirra under penalty of perjury one of the following declarations
❑ 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
❑ 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 are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need riot be completed if the permit is for one hundred dollars ($100)
or Icss)
I certify that in the performance of the work for which this permit is issued. 1 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 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
jI 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 authoria 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
j liabilities, Judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signature of ApplicanUConrractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle h— ous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
Yes No
❑
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment a devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes ONO
I have read the hazardous materials requirements undcrChapter 6.95 of the Califor-
nia Health & Safey Code, Sections 25505.25533 and 25534. I understand thatif the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or authorized agent Date