06090233BUILDING DIVISION PERMIT
BUILDING ADDRESS:
20400 STEVENS CRK BLVD 250
OWNER'S NAME:
PROMETHEUS
)NE:
ARCHITECT/ENGINEER:
p cO LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z OW with Section 7000) of Division 3 of the Business and Professions Code, and my license is
H in full force and effect v a
? License Cl s t Lic• N
p Datc Contractor
ro ARCHITECTS DECLARATION
a< 1 understand my plans shall be used as public records
' u.y Licensed Professional
' O OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
no following reason. (Section 7031.5, Business and Professions Code: Any city or county
0 repair any structure
which requires a permit to construct, alter, improve, demolish, or
prior m its issuance, also requires the applicant for such permit to file a signed statement
? < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
t II-- � (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 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 or
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are 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 thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License law. B & P C for this reason
❑ 1 am exempt under Sec.
Owner Date
WORKER'S COMPENSATION DECLARATION
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1042 HAMILTON COURT
(650)701-1500
PERMITNO.0 6 0 9 0 2 3 3
PERMrr ISSUE DATE
10/25/2006
SANITARY NO. CONTROL NO.
BUILDING PERMrr INFO
Job Description
TI -OFFICE TO INCLUDE E.M.P. MINOR STRUCTURAL
ALL ROOF EQUIP MUST BE SCREENED FROM VIEW.
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 Worker's Compen-
ation, as provided for by Section 3700 of the Labor Code, for the performance of the
vork for which this permit is issued.
-1 I have and will maintain Worker's Compensation Insurance, as required by Section
1700 of the Labor Code, for the performance of the work for which this permit is issued.
vly Workers Com ensation Insurance carrier and Policy number arc:
:airier. AIA t ' Policy No.: 1 5Z'qq — 6�2
CERTIFICATE OF EX MPrION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars ($100)
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 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
I certify that I 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 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 granting of this permit.
APPLIC NDERSTANDS AND LL COMPLY WITH ALL NON -POINT
SOUR E LATIO
Signa 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. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes No
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 Nu
I have read the ha72rdo us 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 tenant that it ' my responsibility to notify the occupant of the
r qui which must met prior suance of a Certificate of Occupancy.
w O -R o
O er or authorized agent Date
Sq. Ft. Floor Area
M
Issued by:
Re -roofs
Type of Roof
Required Inspections
Occupancy Type
Date X/ ti
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
All roof coverings to be Class "B" or better
Date