07120206D :2
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CITY OF CUPERTINO���
BUILDING DIVISION PERMITiC1�OFiMTi('
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LD�I8,�D8US'§TEVENS CREEK BLVD STE
GIDEL AND KOCAL
Pry MI07120206
OW NE
PERMrr ISSUE DATE
PROMETHEUS REAL.ESTATE GROUP
574 DIVISION ST
01/07/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
COMM h L TI , MV ELVTR LOBBY
BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
Dc).
LICENSED CONTRACTOR'S DECLARATION
Job Description
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 licea¢ is
in full force and effect f,'S
License Class Lle.
0 Etc Contractor-
----
ARCHITECCS DECLARA ON
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 mason. (Section 7031.5, Business and professions Code: Any city or county
which requires a permit to convect, alter. improve, demolish, or repair any struhctum
prior to its issuance, also requires the applicant for such permit to file a signed statement
Ft. Floor Area
Valuation
that he is licensed pursuant to the previsions of the Contractor's License Law (Clapaer 9
Sq.
(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 eumption. 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 rive hundred dollars (SSW).
❑ I, as owner of the property, or my employees with wages at their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Six- 7044, Business
and Professions to Code: The Contractor's License Law es not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employ=. provided that such improvements are not intended or offered for salt 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 net 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 U.
eense Law does not apply to an owner of property who builds or improves Oheteoo. and
.
who contracts for such projects with a contract rs) licensed pursuant to theContracWh
License Law.
❑ I am exempt under Sec . B R P C for this reason
Owner Dale
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-iasum 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 huurancc, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is listed
My Worker'sC{{o ensation]avurance carrier and Policy number are: �(
Carrier.Policy Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crhis section need not be completed If the permit is formic hundred dollars (SI00)
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 is to become subject to the Workers' Compensation
Laws of California Date
Applicant
NOTICE TO APPL.ICANf: if, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constructinn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ, C.)
-
Lenders Name
i
Lenders Address
1 certify that 1 have Head this application and state that the above information is
'
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise rcprescnulivcs or this city to enter upon the
above-mcmiuncd property for inspection purposes.
(We) agree to save, indemnify and keep harmicss the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue: against said City
' in conseque a of the granting of this permit
' APPLICANT ERSTANDS AND WILL COMPLY WITH AlNON-POINT
Issued by: Date
SOURCEREGU ON
Re -roofs
/
Type of Roof
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
.as defined by the Cupertino Municipal Code. Cbapter 9.12, and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes 9K.
If a roof is installed without first obtaining an inspection,agree to remove
Will the applicant or. future building occupant use equipment or devices which
.1
emit hazardous air contaminants as defined by the Bay Area Air Quality Managemem
all new materials for inspection.
District?
El yet L7Tu
1 have read the hazardous materials requirements under Chapter 6.95 of the Catifor-
nia Health & afciy Code, Sections25505.25533 and 25534.1 understand that if the building
ty to notify occupant of the
flocs not eurrcn tenant that it an
rcyuircmentswhicbmust metpri saran racenificatemroe p
f a ere pan ft.
Signature of Applicant Date
l T tQ
All roof coverings to be Class "B" or better
Owner or aulhorircd agent hate