04040053 ` CITY OF CUPER'I'INO
BUILDING DIVISION PERMIT CONT,RAGTOWINFORMATION
BUILDING ADDRESS: NATIONAL CONSTRUCTION RENTALSPNo.
04040053
6 N 7 PERMIT LSSUEDATE
OWNER'S NAME:
ANNE LING
NE: SANITARY O OL NO.
ARCHI'IECDENGINEER: BUILDING PERMrr INFO
BLDG ELELT PLUMB MECH
Lop LICENSED CONTRACTOR'S DECLARATION Job De$Cf1pt10It��
YwF I hereby affirm Nat 1 an IittvcO under provisions of Chapter Y(commencing tt fI"�' I�t1 /a ❑ �D
<Z yr with Section 7000).f Division Sof the Business and Potassium,Cade.and any he--is u�(}5Cp1�
"_oma in fell to.and effect. TEMP POWER POLE
i§J? License Class Lic.g
Dau: Cmtrac ar APR 26 2004
ARCHITECTS DECLARATION
I undersland my Puns.hall W used as public mcards
;;t; LicensedPmfession.I BUILDING
OWNER-BUILDER DECLARATION
I mmby affirm that I sm cacmpi from the Contractors License Law future
E 00 following mason.(Section 7031.5.Business and Professions Cale:Any city or county
g 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 annuitant
< that he is licensed pursuant to the provisions of the Connector's li¢vc Law(Chapter 9 Sq. Ft. Floor Area Valua[io
at (commencing with Section 7")of Division 3 of the Business and Profession Coda)of
i $
that he is exempt therefrom and the hnis for the alleged exemption.Any vialation of
Section 7D31.5 by arty applicant for a permit subjects the appimani to a civil penalty of 3 M194`018INUO 0 Occupancy Type
not mom dun five hundred della.($50)).
1,ss owner of de pmprrty,or my employees with wages n their sole compew0on,
will do the work and the swcturt is not intended oroff.ed for(See.7061,Business
and Profession Code:The Contactors License Law docs ml apply to so owner of Required Inspections
property who builds err improves thereem end who does such work hi mself m duough his
own employms,provided that such improvements am not intended orofferW forsale.IL
however,the building or improvement is sold within one year of complNon,the owner-
builder will have de burden of proving that he did not build or improve for purpose of
sale.).
Oil.as owner of the propcny.am eaclusively contracting with licensed contractors to
consumer the project(Sec.7066,Business and Professions Code:)The Contractor's Li.
cease Law dao not apply to an owns of property who builds or improves demon,and
who contracts for such projects with a conuarear(s)licensed pursuant o rhe Contactors
License law.
❑ lam e:emp/ry^tler Sa. ,B&PC for dais moon
ow' Dare �- o
WORKERS COMPENSATI B"� RATION
I hereby affum under penalty of perjury a of the ng dcel.ntiom:
I have and will maintain a Cenificam of Consent to self-umare for Workers Campcn.
eetion,as provided for by Section 3700 of the Labor Code,for the perfmmance of the
work for which this permit is issac0.
❑1 have and will maintain Worker.CarepemNon Insurance,u located by Section
3700 of the Labar Code,for de perfmmanceof the work for which this permit is issued.
My Workers Compensation bournme carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS
COMPENSATION INSURANCE
(Mie it.aced not he completed lithe Permit Is far one hundred dollars(SIM)
in est)
I certify that in the Performance of Ne work for which this Ni nit is issued,I shall not
employ any Person in any manner so as to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOITCE TO APPLICANT:If.afro,making this Certificate of Eatontown,You should
beeone subject m one Worker's Compensation provisions of the"Wo Code,you me-
.JZ forthwith comply with such provisions or this Permit shall W deemed revoked.
zO CONSTRUCTION LENDING AGENCY
(-. 1 hereby affirm that there is a construction lending agency for the performance of
a> the wart,for which this permit is issued(Sec.3091,Civ.c)
dfenders Name
=Z Landers Address
V 0 I certify that I have read this applieaihm and sum that the above information is
U. r correct.I agree to comply with all city and county ordinances and sure laws misting to
0 V building construction.and hereby authorize¢preunulives of this city to enter upon the
�WaWw-metro a l property for inspection Purposes
(we).,ma to sere,indemnify and temp humless the City of CuPertim,against
f'y liabilidea,judgments.Cosa and expanses which may in any way acame&gains,said City
V Z in corsegmncc of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REPyULATION
s/I//2�G �v— Y ¢� Re-roofs
groom ofApplic HrAAZA DOU MATERIALS DISCLOSURE Else, Type of Roof
Will the applicant or future building occupant sm r or handle ha haus memos[
as defined by the Cupenum Municipal Code.Chapter 9.12,and the Health and Safety
odc.Smfion 25532(.)? \rwf All roofs shall be inspected prior to any roofing material being installed.
❑Ys Nu
Wise Pec applicmt o /u�m Willing occupant vsc cyuipmcm or Jessica which If a roof is installed without firs[obtaining an inspection,I agree to remove
mit havardous air contaminants as JCGncd by the Bay Area Air Quality Management all new materials for inspection.
Disuict? ''....,,ff
[3 Yes y�INo
1 have mail Ne bxvardous materials requirements under Chapter 6.95 of the Califon
ria Health k Safety Cnde.Secrous MO.Z5533 vu1255X.l understand that ifte Wilding
does cammly hast a moans that it u my respomibiliry mfily use acupant of the
rey mmen u 'chmuuWmct ' rmismanet.racesii eofOccuamy. Signature of Applicant Date
¢ ° All roof coverings to be Class "B"or better
Owner ser authorircJ agent U
Dan,
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEI�TINO
Building Department
JOB ADSS: / /7 Cr I J Y p Ct PERMIT #
1� / T GC I
OWNER'S N y)-p— PH # o U z' 2—2,U21-
GENERAL
,UGENERAL C RACTOR F
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishinge4 f
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�✓ v
b
Own r/ tr for ature Date
CITY OF CUPERTINO cs�
TEMP POWER 6
\IFCITY OF UPERTINO PERMIT APPLICATION FORM
APN # Dater/ 8(
Building Address:
oo± Cl iorc� C�
Owner's Name: L-i C40 S)
Contractor: N Phone: License #:
Contact: Phone: Cupertino Business License #:
Has- CI D A 408 8 z - o4-
Building Permit Info:
Elect 9
Job Description:
Residential`/ Commercial ❑
Cost of Project: ZSo
A li le Fee ID Fee Description Fee Group
TEMP Temporary Power ELECTRICAL
PERMITTEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
7- 3 OZ --�