07020024CITY OF CUPEKIT
BUILDING DIVISION
Bu1LgZlrbcDDREsSERMIT NO.
STEVENSTEVENS CREEK BLVD NOVO CONSTRUCTION 07020024
OWNER'S NAME: PERhIIT ISSUE DATE
PROMETHEUS 1042 HAMILTON COURT 02/06/2007
PHONE: SANITARY NO. CONTROL NO.
(650)701-1500
ARCHITECTIENGINEER: BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
vith Section 7000) of lD ' on 3 of the Business and Professions Code, and my license is
n full force and effect.
.teen Class Lic. N t
)ate Contractor A CC
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
.icenscd Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
oolowing 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 die applicant for such permit to file a signed statement
chat he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
chat 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
.at more than five hundred dollars (SSW}
❑ L 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 Contractors 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 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 U.
cense law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a conuaclor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec. . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 bereby affirm under penalty of perjury one of the following declarations:
❑ f 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.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code• for the performance of the work for which this permit is issued.
My Wor�AARnFICATE
Camdon Insurance carrier and Policy number are: �/Q ,,/� �
Carrier. PolicyNo.:--(, ZE IAt.�6
OF EXEMPRON FROM WORKERS'
l,Mderrp -;I COMPENSATION INSURANCE
(rhis section need not be completed if the permit is for one hundred dollars ($I W)
or less.)
1 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 Workers 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. 3091• Civ. C.)
Lenders Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
correct. 1 agree m comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise 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 consequcn of the granting of this
APPLIC NDERSTANDS AND ILL COMPLY WITH ALL NON -POINT
SOUR L.AT
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Sign Zurf App icanl/Conlractor Date
HAZARDOUS MATERIALS DISCLOSURE
the applicantor future building occupantstore or handle hazardous material
as dy the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
❑ Yes '01°
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as eftncd by the Bay Area Air Quality Management
District?
Cl Yes No
Job Description
INTERIOR DEMOLITION ONLY OF OFFICE/KITCHEN
Sq. Ft. Floor Area $25000 Valuation
3 6 9 0102 9 W Number Occupancy Type
Required Inspections
Re -roofs
Type of Roof
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.
1 have mad the hasardous materials requirements under Chapter 6.95 of the Califor-
niaHcal &SafctyCodc,Scctions2 5.25533and25534.1understand that ifthe building
does o rrcntly have a tenant, th it is my respoosihility to notify the occupant of the
rcqu ts wh;C m be met pnVr to issuance of a Certificate of Occupancy.
0 cr or authorized agent Date
Signature of Applicant Date
All roof coverings to be Class "B" or better