02100023 CITY OF CUPEW11NO
RUILDINC DIVISION PERMITCONjTRACTOR IANFORMA�TION
99
BuB1)f+cBA018EsBU33 RD CALIFORNIA POWER AND LIGH PERMrrbR02100023
oW!,KK)P*EHELEN D ET AL 8887 LILLY AVE APPLICATIT1��IyPr ,5, 2002
orZONE: 4088470520 SANITARY NO, // �� �� CONTROL NO.
ARCH TT;CT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
p�00 LICENSED CONTRACTOR'S DECLARATION
s U afford I hereby affrthat 1 am located under provisions of Chapter 9(commencing Cr p
<t,, with Section 70sB ol'Divtsion 3 of the Businc..e PmfestionsCde,and my license is
SERVICE UPGRA U� AMP
Fp,e in full! Jeffs ✓" p�
hZ License .�F O Lic.N 6
D Cnnvachtr
--'�' RCIIITF.CTS DEC TION
mI understand my plans shall be used as pit lie r... s
apwaV
ttkii it� Licensed Professional
0
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor License law for the 2 O O O
i n P X0O following reason.(Section 7131.5,Business and Professions Code:Any city or county
Lai which requires a Permit to aonstiuct,alter.improve,demolish,or repair any struemrt
prior or its issuance.also requires the applicant for such Permit to file a signed statement
z<
list he is licensed pursuant it)the provisions oftheConumtors License Law(Chaprerr) :Nq2Hd.ffM&E)A10A Valuation
em l_'p (commencing with Section 7000)of Division 3Of the Business and Professions Cale)or
a 3 that he is exempt dice fmm and he basis for the alleged exemption.Any violation of
Section 7131.5 by any applicant for a permit subjects the anplicand to a civil penally of PNN
add more man five hundred dollars($500). Occupancy Type
El L azowner of Me property.or my employees with wages az their sole compeasxtion. 304 — ROUGH ELECTRICAL
will do me work.and the slruclum is not intended or offered for sale(Sec.7004,Rusiaess
and Professions Code:The Contractor's License Law dors not apply or an owner of equtre nspections
property who buildsor ed that
thereon.and who docssuch work h r offered
own employees.Provided that such improvements are not encoded or offered for sale,If,
owner-
beweveatheavetngordeno vincra issold hatheldnot year of completion,og theose of
builder will have the burden of proving that be did not Wild or improve for purpose of F p(�n A L E 90
sale.). I[— 8 Q9
❑1,as owner of the pmpeny.am exclusively contracting with licatsed contractors to q
construct 714
wthe projecl(sec. 0.Business and Professions Gbe:)The Contractor's Li- OCT O l 2002
ses law Jars not apply to an owner of property who huilds or improve yt
memon,and
ho dfi for such mje<ts with a contractors)licensed pursuant me Contractors
Li rise Law.
Ism pt unJerStt. ,B&PCfor this rcazon
Owner -. Date —o BUILDING
WORKER'SC NSATION DECLARATION
crcby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Ccnifcate of Consenuu seif-imam for Worker's Compen-
amion,as provided for by Section 3700 of me Labor Cod,far the performance of the
work for which does permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,M required by Section
170nd the tabor Code,for Me performance of mew rk fyy��whicn this permit is ieneJ.
My Worker's Compcossiun Insurance cavies iCy'humher arc:
c,: cy No.:
CERTIFICATE 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the Permit Is forme hundred dollars IS IW)
less.)
1 certify that in the performance of the work for which this Permit is issued,1 shall not
employ any i
7tipp tanners,TS I,, Inlg Fubl I i
to the Workers'Compensation
Lawxof Califoreia.D c rB' h �
Appl p ^
NOTIpd TO I.after making cls Cemfcate of Exemption,you should
hcenme subject vincurs Compensation provisions of the LaMu Code,you must
CQ forthwith comply with such provi.sinnsorthis Permit shallM deemed riveted.
z CONSTRUCTION LENDING AGENCY
F+ Ibt alarm tout More is a construction lending agency for the perfurmemYof
94 the work for which this Permit is issued(Sec.3097.Ci,C.)
W Q Lender's Name
6. lenders Address
Z
O Q 1 certify that 1 have read this application and sum that the above information is
Iy H correct 1 agree to comply with all city and county ordinances and sure laws relating m
OU but ldi ng construction,and hereby nation m represcnWlives of this city to enter Open the
above-mentioned properly for inspection purposes.
H M (We)agree to save,indemnity and keep harmless Inc City of Cupertino against
h liabilities.judgmenq costs and expenses which may in any way accrue,against said City
V z A APPLICANT
UNDERSTf Me ANDS
or this permit.
APPLICANT UNDr:RSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE RRGU S. Issued by: Date
Re-roofs
gnamrco vapor Date
IAZARDOUSMATERIALSDISCLOSURE Type of Roof
Willm applicant or future building twerapantstme or handle hvaNuus material
as defined by the CuMninn Municipal CtNc,ChaPmr 9.12,and Inc Health and Safely
cede.otye,ans" D nth - All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Main,building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit has orous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District P
❑Yes Qy�
I nave read the hamaNnus mamfialsrcquircmcnts once,Chepmr 695 of thc Caltfoh
nits Health At Safety Code SutionQ55115,25533 and 25514.1 uddersrml that if be,Wilding
tea net CmTr tly have a[scam,mat it is my resicasibtltty Io nntilY InC tYfu I n(mL'
cyuimnen ten mus(he met t It,issuance Ofa CcNficam I Oc Signature of Applicant Date
3
Dw agent D„e All roof coverings to be Class "B” or better