03120057CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CQNTRACTOR INFORMATION.• •;
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BUILDING ADDRESS:
NOVO CONSTRUCTION
PERMIT NO 03120057
-"NER'S NAME:
PROMETHEUS
420 MAPTR qT
PERMIT ISSUE DATE
2
PHONE:
(650)701-1500
SANITARY CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm I am under provisions of Chapter 9 (commencing
P
Dthativision
withSectionndeffifDivinion3 of the eusinexs end Profcuions Cnde, end mylicense ix
f1h, Business
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in full frca nnderreet -
TI--7 & 8TH FL.STAIRS/ FINi41L�ED
License Class ti
Dem Contractor
ARCHITECTS DECLARATION
I understand my pians shall be used as public mentis
FEB 2 6 2004
Licensed Professional
OWNER-BUILDER DECLARATION
I h.mlay affirm that 1 .m exempt Bum the Contractor's License Law our the
BUILDING
following reason. (Section 7r'131.5, Business and Processions Code: Any city or county
which requires a permit in construct, allele improve, demoli.¢h, or repair any nlructure
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poor in its issuance, also requires the applicant forsuch permit to File a signed statement
that he is licensed pursuant to the provisom of the Contractor's License Law (Charter 9
- Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Coda) or
that he is exempt thcmfmm and the basis far the allcgcd cacmpthm. Any violation of
Section 7031.5 by any applicant for a permit subjects to applicantto a civil penalty of
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3 aFN1`ItAlb8er00
Occupancy Type
P Y YP
not mom man five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages an their sole compensation.
will do the work, and On structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law dome nail apply to an owner of
Required Inspections
property who builds of improves thereon, and who docs such work himself or through his
own employees, provided that such improvements are not intended oroRered for sale. If,
however, the building or improvement Is sold within ane year of completion. Ne owner.
builder will haus the burden of proving mat he did not Wild or improve fur purpose of
..
Ku
I, as owner of the property, am exclusively contracting with licensed contractors to
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mel the project (Sec. 7844, Business and Professions Code:) The Cmismau rs Li
cense law does not apply to an owner of property who Wilds or improves themon, and
ntracor (welt pr cm..th.c.ntrntor(s)ticcnmdpunuanno the Contractor's
e Law.
m exempt d c. ,B&PCf thl on
;/tM.y
1DECLARAT N
7=under
Penalty of !jury one of the f OwingOulantiom:
❑ 1 have moil will maintain a Certificate of Conum toself-irmor for Worker. Cumpen-
nation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 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 art:
Cartier, Policy No.: _
—EXEMPTION
CERTIFICATE OF FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the Permit is forum hundred dollars (SI0U)
or loss)
1 cenify mat in the Performance of the work for which this permit I. issued. l shall not
employ any Permit in any manner an as to become subject to the Workcre Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IL otter making thin Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you mus
.
.
forthwith comply with such provision or this perm it shall be deemed mvelmd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm mat there is a construction lending agency for the performance of
me work for which this Permit is issued (Sm. 3097, Civ. C.)
Leader's Name
Lenders Add.
1 cenify mat I have read this application and Ones that the all information is
correct. l agree to comply with all city and county ordinances and sale laws relating to
building construction, and hereby authonae representatives or this city to cnmr upon the
above-memfned property ret inspection purposes.
(We) agree to save, fi dcmnily and keep harmless the City of Cupertino against
liabilities, judgments. casts and expenses which may In any way acetic against mid City
in con aegmna ofineg ting of this monnil.
APPLICANT U E ANDS AN COMPLY WITH AL NOpI-POINT
Issued by: Date
SOURCE RE .a /
Re-roofs
Type of Roof
Si m of Appltcam/Contmcior Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecupant store or handle haverdon material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
We. Sections25532(.)? Na
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All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan inspection, I agree to
Will the applicant or Nhom building Occupant use equipment or devims which
P g remove
emit hazardous air commitments as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes
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I have mad the he resmrials requirements under Chapter 6,95ofthe Califor-
niaHcalm&SafjhSeetiom25505.M533and25534.lundcm=dthetifthe building
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does not curtertenant. mat it is my responsibility to nodry the me ant of the
requimm ts oorn'o lm iamance.faceroficamof cup cy.
71
Signature of Applicant Date
All roof coverings to be Class "B"or better
cr or authorixcJ agent
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