07020131CY OF CUPERTINU
BUILDING DIVISION PERMIT
TEVENS CREEK BLVD
OWNER'S NAME:
PROMETHEUS RE GROUP
ARCHITECTIENGINEER:
O C) LICENSED CONTRACTOR'S DECLARATION
U
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is
t < a in full fo¢e and effect�^t 7 �.
nz License Class
F„ Date Contractor
ARCHITECT-S DECLAR
1 ern ratan my plans shall be used as public reds
syU
O Licensed Professional
OWNER -BUILDER DECLARATION
t I hereby affirm that I am exempt from the Contractors License Law for the
f O O 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 structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Gthat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
i F- (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 dollar (ZW0
❑ 1, 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, Busmess
and Professions Code: The Contractor's 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 oroffeted for ale: 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 contactors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors U-
eense law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractors) licensed pursuant to the Contractors
Lkene Law.
❑ I am exempt under Sec . B & P C for this mason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby alrum under penalty of perjury one of the following declarations:
❑ 1 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. _
�avc 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 Work Com pe Insurance carrier and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION 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 Workers Compensation provisions of the Labor Code, you must
z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
.� C/)
(•-t ►. I hereby affirm that there is a canswction lending agency for the pvfarmance of
> the work for which this permit Is issued (Sec- 3097, Civ. C.)
a Q Lenders Name
Lenders Address
:Dz
U 0 1 certify that 1 have read this application and state that the above information is
LL+ correct- I agree to comply with all city and county ordinances and state laws relating to
0 U building construction, and h reby authorise mpresentatives of this City to enter upon the
W above -mentioned property r inspection purposes
Q. (We) agree to a indemnify and keep harmless the City of Cupertino against
Fr1 liabilities, judgmens,co and expenses which may in anyway accrue against said City
U z in co q ce of the g ting of this permit.
►" APPL A U ANDS AND WILL COMPLY WITH ALL ON POINT
SOUR
s
Signature f Applican or ' Dale
HMARDOUS MATERIALS DISCLOSU
W the applicant or future building occupant sore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(s)?
' ❑ Yes o
Will the applicant or future building occupant use equipment or devices which
cmlt hazardous air contaminans as defined by the Bay Area Air Quality Management
District?
❑ Yu a
1 hav mad the hasard0us mate ' Is requirements under Chaptcr&95 of the Califor-
nia (icalnh & afety Code, Sections 25 5, 25533 and 25534. I understand that if the building
does not cu dy is my responsibility o noddy the oce pant of the
requirements m pri ante of a Certificate: of pe _
TBD - TO BE DETERMINED
PERMrr NO.
07020131
PERMrr LSSUE DATE
06/13/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
REPAIRS -ELEVATED WALKWAYS, STAIR LANDINGS AND
PRIVATE BALCONY REPAIRS TO APTS.
Sq. Ft. Floor Area $ 3 6 0 0 0 0 0 Valuation
3 6 9 010 2 6 Aftl Number
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
Type
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
Date
Owner or
All roof coverings to be Class "B" or better