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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
•• CONTRACTOR INFORMATION f"
�•
BUDAINGADDRESS:
CERTIFIED ELECTRIC INC
PERMITNO,
922 BLAZINGWOOD AV
03010038
OWNER'S NAME:
14781 POMERADO RD
APPLICATION SUB DATE
KALBAG SURESH M AND SUMAN S
01/07/2003
HONE:
(800)521-1495
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 herchy affirm that 1 am licensed under provisions of ChapMr 9 (commencing
p
with Section 7f tib of Division 3 of the Business and Professions Code, and my license is
Nmuforce and,rfeC/ 3 (� 3 -24 7
UPGRADE ELECT SERVICE TO 200PRNALED
Llcenac Clue p�[�.� It M
Date e�/O� Cnmfor t
As shall lyase UECLARA N
1 undersunJ my shall W used as records
FEB 1" 8 2003
plans public
Licensed Pormisinhul
OWNER BUILDER DECLARATION
I hereby .(firm I oro )Bumph from the Contractors Licensee Law for
BUILDING
following reason. on 703 1.5, Business and Professions Code: Any city or mumy
ampit in
which, repair any structure
ivcs a permit In consumer. attic tit firav),
the applicant fur such onis tot
its also h Permit t fi signed s
prier 70 its anon
Sq. Fl. Floor Area
p�o[IO❑
pursuant to the ice hapten
p
Nat Imescingwiit puuuam 70th)ofDiviao of the Comment'sBusiness
$4
of Division3 of the Business and Professions Cadq or
(commencing with Section Code) or
Nat he u eumpl therefrom and the basis for the alleged exemption. Any violation of
and
Occupancy Type
Satlon 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not more thm five hundred della. ($500).
Las owner of the pmpeny, or my employes with wagesazNeh sole compensation.
— UFER
will dote work, and th,nrocmm is not intended or offered for age (Sm. 7,1,1, Business
and professors Code: The Contractors License law dos not apply to an owner of
property who Wilds or improves IWmon, and who doessuch work himself or through his
304 - ROUGHons
own employees, provided that such improvements art not intended or offered forme. If.
505 — FINAL ELECTRICAL
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 Wild or improve for purpose of
sale.).
1, as owner of the property. am exclusively cantescling with licensed contractors to
construct the project (See. 70a. Business and Professions Code:) The Contractors U.
cense Law does not apply to an owner of property who Wilds or improves 1Wmon, and
who commets for such projects with a contraclor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec. . B & P C for this chsen
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby'E mmunder penalty of perjury one of the following declarations:
I hove and will meinuin aCertificate of Continuo self -insure for Workers Compcm
s own. az provided for by Section 37M of Ne Labor Code, for the performance of the
rk for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as mquired by Section
700 of the labor Crack, for the performance of the work for which this permit is issued.
My worker, pe sation uxurutcf�/carrier and Policy number spec: /
Carrier':W '� x_ /�--- Policy No.: { � g7 5`is "�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed if IW permit is forms, hundred dollars ($100)
or to..)
I certify that in the performance of the work for which this Permit is issued, I shall not
employ any person In any manner N ai it) become Subject to the Workers Compensation
Laws of C.Iifi m .. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cenilicak or Exemption, you should
become subject to the Worker's Compensation previsions of the Labor Calc, you must
forthwith comply with such provisions or this permit shall W deemed mvnked.
CONSTRUCTION LENDING AGENCY
I hereby o irm on, there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3197, Civ. C.)
Lender's Name
Lender's Address
I certify chat 1 have read this application and sum that Ne above information is
correct. 1 agree to comply with all city and county ordinances and auto laws relating to
building cam uction, and hereby million. rcFicaenutives of this city to merupon the
above-memimad preperty, for inspection purposes.
(We) agree to save. indemnify and keep harmless Ne City of Cupertino against
liabilities, judgments. costs and expenses which may in any way accede againstsaid City
in consequence of the granting of this permit.
APPLICANT UNRSTANDSAND WILL COMPLY WITH ALL NQNPOJNr
NT DE
Issued by: Date
UDE
SOURCE
Re -roofs
Type of Roof
7 3
Signature of ApplicantiCamractor ❑❑ tic
UAZARDOtfSMATERIALSDISCLOSURE
Will the applicant or future Wilding occupant store or handle hamrdous around
at defined by Ne Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Ltrnd,. Section 2553200?
Yea bwr—
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
Will the applicant or future Wilding occupant use equipment or devices which
MIL havanduus air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District/
`
❑ Ycs Clint
I have read the humorous materials mquismenu under Chapterl.95 of the Califor-
nia I [color & Surety Chalo, Sectlons25505, 25533 mi I undersund thstif the building
,res not currently have u tenam. Nat it is my responsibility m huffy IW recap.[ of the
requiremcns datW mpnarmiaz ))ar;CedlfieatenfLk.'eov y.
Signature of Applicant Date
Z=Z=
All roof coverings to be Class "B" or better
D
Dome((" amhari.eda m e