04030178 JNER'S
OF CUPERTINO "' �'
ILDING DIVISION PERMIT CONTRACTORANFQRMATION�,
�.usZ
G ADDRESS: PERMIT NO.HANDYMAN NETWORK 04030178 NAME: PERMIT ISSUE DATE-
SA
NRARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
u00 LICENSED CONTRACTOR'S DECLARATION JobDescrip[ion
W
❑ 1 bunchy affirm Nse
at 1 am llcand under previsions of Chapter 9(commencing
ZE with Serfion7")of Division3oflWBu4nessand Professions Codc,vndmyliccnmis
infull rm«and ana REVISION--IN HOUSE USE ONLE
O LI z Lienee Class
Lis.10
I o Dam Contractor NO NEW PERMIT ISSUED ORIG. #04030132
ARCNITEC Contractor
DECLARATION
IN I understand my plans shall W used a public records
pyU
ma t; Licensed Professional
OWNER-BU ILDER DECLARATION
31 bitchy,Rrm that I em exempt from the Com"'wes License Law for the
a0 following season.(Secuun 71G 1.5,Business and ProfusioM Cafe:Any city or county
m whim aqui.a permit to consumer,.he,improve.demolish.or repair any structure
prior to its issuance.also requires the applicant for such Permit o file a signed statement
FSCthat he is licensed Pursuenlmthe,provisions ofdo,Convacmr'sLt...Law(Chapter 9 Sq.Ft. Floor Area Valuation $0
'l- (commencing with Secbon7")of Division 3 of the Business and Professions Cale)or
$ that k is exempt therefrom and the buts for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects tW applicant to a civil penalty of APN Number Occupancy Type
not a=dean five hundred dollars(SSW).
1,u owner of the propmy,or my employees with wages As their in eompenmtlon, 36938022 . 00
will do the work,end Ne Amicume is not intended or Wind!for Asia(Sec.7004,Business
and Processions Code:The Conmaolh Lleeve Law dons not aPP1Y m In owner of Required Inspections
property who Wilds orimpfovea thereon,and whodoessuch workhimselfor through his
own employees,provided that such improvements an not intended oro@rW for sales If,
however.NC Wilding or improvement is sold within one year of mmpleuon.the owner. n
builder will hoe the burden of proving Nat W did not Wild or improve for purpose or C'
sale.).
vl,as owner of the progeny,am exclusively contracting with licensed coa.m.to
..Metuse
es jet(Sec.n an Business and Professions Code:)TW vasC.dar on.at's Li- \ S
cefve hum alas era apply m an owner of PropenY who W ilds or Improves thereon,anal,
whocomracuforsuchpmActsm ace arts)licensed pursuant to the Contractor's \
License law.
❑lam exempt un Sec. ,B&PCf rthis nsson
WORKER'S COMPENSATION DECLiUll
1 hereby Affirm under penalty of perjury arc of the fallowing derivations:
I have and will maintain a Certificate of Consent to self-insure for Worhr'sCaoper-
sation,As provided for by Sauon 37M of the labor Cotlo,for the performance of she
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as"Aired by Section
37W of the IaWr Code.for tW paformsuce of the work for which this permit is issued.
My Worker's Compensation Insurance cmier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not becompleted ifthe permit Is foram,hundred dollars(SIM)
or Mss.)
1 unify Nat in thc performance of the work for which this Permit u issued.I shall not
employ anyperson in any manncrso As re bceomc subject o IW Wof WCompensation
Laws of California.Da¢
Applicant
NOTICE TO APPLICANT:IL after making this Campeau,of Exemption,you should
become subject to Ne Wmkeh Com,.,ion provisions of the Ia Wr Code,you mint
you
foMwith ..,Ly with ns such provisioor Ni,permit shall W deemed invoked.
z ` CONSTRUCTION LENDING AGENCY
F. Ihereby Mo.that Nen is a cunsv ,bre Imilft.,ency for the Performance of
tYiIMC work for which this Permit is issued(Sec.3097,Ci,C.)
0 A Lender's Name
CL
Z lender's Address
U 0 1 certify that 1 have read Nis application and sate that the aWve inrormatimt is
H cortex 1 agree to comply with all city and county ordinances and sun laws mlaung m
0O building construction.and hereby authentic tcprnsentativre of this City to enter upon the l
r shove-(We). re be ertysave for cmnify An purposes. I
liabilities,
a
(We)agree m cast,indemnify and kith harmless the City of Cupertino s against
TYy into Wequenc mints,I.and A I is expenses which may in anY way accmc against said City /
U Z APPLICANTCUNDERSTANDStANN t COMPLY WITH ALL NON-POINT Issued by: Date
SOUR EREGULAnyt. 3 9 -
Re-roofs
sur ApplinMContractor .�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mcupanuton orhandlc hvudous material
as defined by the Cupertino Municipal Cod,,Chapter 9.12,and don Health and Safety
aka section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
0Yes Nu
Will the ep0licam or nonce building occupant sew equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
emit Iterations air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Dumet7
p Ye,
I have read the Wrox trials requirements under Chapter 6.95 ofthe Caller.
Am Healon&Safety Cade,Seedom25505,25533 and 25534.1 umkrsmod due ifde Wilding
does not emend,WOO a Nnan4 dial Il i,myunity m nobly the 0.cuPsm or the
req 'mm is hich pet tenter to of, finte er o,ta anry. Signature of Applicant Date
Owner r.nm rd agent 3 a ,,, All roof coverings to be Class"B"or better
CITY OF CUPERTINO
BUILDING DIVISION PERMI0 'CONTRACTOR INFORMA' '_-
BUILDING ADDRESS: PERMIT N0.
HANDYMAN NETWORK 04030178
OWNER'S NAME: PERMITISSUEDATE
MART4:9
PHONE: SANITARY OL NO.
ARCHf1ECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo
LICENSED CONTRACTOR'S DECLARATION Job Description
F I hsmby affirm that I am licensed under provisions of Chapter 9(commencing
2W wbb SCCion7t]70)cf Division 3of Nt Buninee,sndprofessioru Code,andmy Internet.
Z win full force and effect.
�q3 Lieenss ala.. Lie.a REVISION--IN HOUSE USE ONLE
—o Dat Cmanclor NO NEW PERMIT ISSUED/ ORIG. 404030132
�8 ARCHITECTS DECLARATION
41 1 motorman my plans shall he used as public records
7C,U
Z o� Licensed Pmfcssumal
S OWNER-BUILDER DECLARATION
<I I hereby affirm that I am exempt from the Convector's License Law for the
—p o following mason.(Section 7031.5,Business and Professions Cats:Any city nr county
which rtquirts a permit to construct.alter,improve,demolish,or repair any stmcmre
prior m its issuance,also acquims the applicant for such permit to file a signed summcnt
< thea he is licensed......I to the provisions of the Contractor.License"w(Chapter 9 Sq. Ft.Floor Area Valuation So
¢�� (commencing wi th Section 7")of Division 3 of Ilan Business and Professions Code)or
an
Nat W Is exemia therefrom and the basis for the alleged exemption.Any violation of
rSccuon 7031.5 by arty applicua for a Permitsubjecu the applicant to a civil penalty of AP N Number Occupancy Type
not mote Nan Eve hundred dollars($500).
❑ I.ssowncr of the property,or my employees with wages as their sole compensation, 36938022 . 00
will do the work.and the structure is not intended or offered for sale(Sm.7014.Business Required Inspections
and Ptafessioru Cade:That Convsctori License law does nal apply to owner
an of q P
pmpenywho builds or impoomthereon,and whodoessuchwmkhimaelf or through his
own employees,provided that such improvements an notinionded or offered for sale If,
however,Ne building or improvement is sold within one year of eomplcdo.,the owncr-
builder will have she burden of proving that he did not build or improve for purpose of
sale.).
15, a owner of the property,am exclusively convecting with licensed Contractors to
construct the project(Sec.7004,Business and Professions Code:)The Contractors Li-
cease Law docs not apply to an owner of property who Wilds or improves thereon.and
whoconeracu
forsuchpoAmwitha ees)licensed personal the Convenors
Lk,.Law.
p t,am attempt andr Sets, B k P C 191 Nu reasontose
WORKERS COMPENSATION DECLARATI ' g
kII hereby affirm under proaBy of perjury arc of the following dedanlianz
have and will maintain a Ceni tame of Consent to self-insure for Worker sCompc l-
sation,as provided for by Section 37M of the labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Workers Campnuauan Bumance,u required by Senior
37W of Use labor Cade,for Be,performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Obesection need not W completed Rthe Permit is for one hundred dollar.(2100) -
orless.)
I certify Nat in the perfommaec of the wart for which this permit Is issued,l shall not
employ any person in any manner an as m become subject to the Warkcri Comperuauaa
Laws of California.Date
Applies.,
NOTICE TO APPLICANT:If,after making this Ccnifrcam of Exemption,you should
become.object m the Workch Compnuation provisions of she IaWr Code,you must
roMwith comply with such provisions or this perm it shall W deemed revoked.
zO CONSTRUCTION LENDING AGENCY
f-a I hereby affirm that there is a Construction lending agency On the performance of
Z' the work for which this permit is issued(Sec.3097,Civ.C)
aQ Lender's Name
Z landefs Address
U O 1 certify that 1 have read this application and sate that the above inrmaatiun is
U. E., cone[t,lagree to comply with all City and county ordinances and sum laws minting to
�(J building conswcaion.and hereby adfunin apresenlatives of this city to enter upon the
r[21 ahavc (We) cd 1.saw for inspection keeps _
(Wjuagreemsees indemnifyand tech hay inmtWCity of me against said
liabilities,joce of the,noing expenses which may in anyway secret against said City
O z A consequence of UNDERSTANDS
of tris perm',.
APPLICANT UNDERSTANDS AND• COMPLY WITH ALL NON-POINT Issued by: Dale
SOUR E RE LATI
u� 3/ Re-roofs
mmrS4 Apprcmucontractar _Pete -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fee..building ace.panurore or handle h.Oml material
as defined by Be Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Se[uezss3z(a)7
Yes
f All roofs shall be inspected prior to any roofing material being installed.
.0 'V/(J�N�u
Will the epplicam orYumm building ocaupamvu cyvipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mt haran nus air contaminants at defined by the Bay Area Air Quality Management all new materials for inspection.
Disvin7
0Ycs u'
[have read the hmaN us materials rtquirtmenu under Chapter 6.95 mile,Califon
nice Hralth k Safeay Cork,Secdons25505.15533 and 25531.1 undenmnd thetirthe Wilding
does WI Currently ha •tent,Nat it u my ibility to nod fy the occupam-of use
my'mm mwmt w ass anet pdortois" sora fatear3ta arty. Signature of Applicant Dale
owner ream cd agent ase All roof coverings to be Class "B" or better
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1 (�C- *ITY OF CUPERTINO*
CUP TYOF O PERMIT APPLICATION FORM
APN # ate:
/2 ; do`
Building Address: ailing Address (if different fr uilding address):
x.03 ? Ca� sof" S'nILI
Owner's Nam
Ha,-L,
Contractor: License #:
Contact: Phone: Cupehino Business License#:
Fax:
Building P it Info:
Bldg t ❑ umb ❑ Wch ❑
Job escription:
Residential ❑ �C erG
Sq.Ft. Floor Area:
Cost ofProje Occupancy Group:
3 b-oo.
Type of Cotruction: Please check this box ' e-pxoject-is a
second-story addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax —Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > IOOOA ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY - Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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