04030047 CI'LY OF CUPERT[NO " h M
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
a ILDINGADDRESS: NICE & RIGHT CONSTRUCTION �a""04030047
OWNER'S NAME: PBRMIT ISSUE DATE
MING
ONE:
SANITARY O. CONTROL NO.
415
ARCHITECTfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uo0 LICENSED CONTRACTOR'S DECLARATION
FC 1 humby affirm wt 1 am licensed under PmVlgmo of Chapter 9 merame«ing Job Description
zW with Section 7WO).Doniton 3mf Ne Busin/esss orb Profassm.Code.and my license is �' �
^<y in full forces dddfect. Ljcall'" �32I4-S}�i TEMP POWER POLE LE
Liccnx Cl...
p Dam 2 1 9 1 0 si- CmUmetm o
AR-11 ECPS DECLARATION MAR 0 8 2004
-t hmdon�,QJ my plans shall W used as public records
Jy
3Gr Licensed Professional
3 Oat I am exempt
from
DECLARATION BUILDING
1 hereby aRrtn Nn I OWNER-BUILDER
from the RATIOlmfa Liccnx Law for the BUILDING
00 following mason.(Section 7031.5,Business and Professions Code:Any city Or county
x m which rernorea a permit m Conslmm,aloft improv,demolish,or repgr any comment
m�'^ primrmiu isswncc.atm requires tM aPPlicam for s«h permiuo Ble asigncdxutemcm
Nmhc uliccvcdpurmantmthcpmvisiomof Nc Com tor'sUa=Uw(ChapW9 Sq.F[.Floor Area Valuation
U,Fp (commencing with Section 7000)of Division 3 of roc Busiw+.and Professions Codc)or
Nat he is exempt therefrom and one basis for In alleged exemption.Any violation of
Section 7031.5 by any appli.1 fora permit subjects Ne applicant to a civil penalty of 32VN20j#ber00 Occupancy Type
not more Nan Esc hundred dollars(1500).
❑1,as owner of the property,or my employees with wages ss Ne,r mlc compensation,
will do the work and the structure is not intended or offered image(See.7004,Business
and Professimu Code:The Contractors License Law dines not apply to an owner of Required Inspections
Ownproperrymploy b,proOkimPmwschimprandwno am no,ihw«k h;mxlfm,through his
Own employers,provided Nat nmentps mid within
art not ear dedoto oroffempleti rd the Owc.ner.r.
bowevrq the building or improrowing
sold within one year of completion,the owner-
builder will have Ne burden of proving Nu he did no,build or improve for purpose of
sale.).
❑su u mvncr of ct property am udus ad contracting Code:)ran
conoacmrs i. O
construct the not
eo an Business ad Professions Code:)The Contractors red
cense Law dots not apply a an owner of property who builds or ant to
Contra and.
who amtncu for such projects with a contracmr(s)licensed pursuant m Ne Conmumri
0Iem eacmpt under Sec. .Bh PC for Nu rcawn Q
Ownc, Dale J�
1CaWORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Ne following declarations:
,�1 haw and will meinuin a CeniOeate of Conxm m selLinsurt for Workers Compere
sation,as provided for by Section 3700 of the Labor Code,for the pedormanec of be
work for which this permit is issued.
I ban and will mountain Workers Compensation Laurance,a,required by Section
3700 or be Labor Code,for the performanee of the work for which Nu permit is issued.
My Workers Compensation Insurance carrier and POEry qu�m(W,ane:
PolicyNo.: ,�'av2o9�9-D3
CERTIFlCA O1 PDONFROMWORKERS'
COMPENSATION INSURANCE
This section need not M completed if the Penni,is future hundred dollars(SIM)
or less.)
1 mortify that in the Performance of the works for which this Permit is issued,I shall not
employ any Person in any manner m a at become subjest to the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making Nu Ccnifimm of Eaemp,imn.you should
become subject to the Worker's Compensation provisimna of thin labor Cook.you must
0Z foMwun comply with such Provisions ase this permit mail be deemed revoked.
zO CONSTRUCTION LENDING AGENCY
[- l hereby affirm Nat dere iso emmencticn lending agency for the peffurman¢of
a> the work for which this permit is issued(Sec.3097,Ci,C.)
Lender's Name
z Lender's Addmss
U I Cenify that I have read this application and sum Nat the above information is
^� Correa 1 agree to comply with all city and county onlimmu cs and than,laws mlm;ng to
0U building construction,and hereby author,ae reprtxn,atims of this city to enter upon Nc
>' W anove-menioned property for inspection purposes.
f'
(We)agree m save,indemnify and emp harmless 0m City of Curmuno agunst
� liabilides.judgmcnu,costs and operates which may in any way accrue against sod Cary
U z in consequence of the gmnhng of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR GULATIONS
� AZARD 4 �
Re-roofs
Sitt A'IiCm Conemr Al
ERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant Smit or handle haaallou,material
as dcrined by Nc Cupertino Municipal Code.Chapter 9.11,and,he Health and Safety
we,semen zss3z(an All roofs shall be inspected prior to an roofing material being❑Yes R No P P Y g g installed.
Will mea Bearer or r7mCmre building«em ant ax equipment or devme,which
I If a roof is installed without first obtaining an inspection,I agree to remove
pp g p quipmen
it W.A..air contaminants as defined by Nc Bay Arta Air Quadity Management all new materials for inspection.
1d.6,
strict
❑Yes p No
I haw mad the hmaNn1usmu` erials requirements under Chapus6.95 ofthc Califon
Health&Safety Cade.Secrom 15X)5,15533 and'3534.I mucu
rsnd thin iHM building
csserercurrentlyhaw•unant.Nat n u myreaporaihility m nmdf Nc occupant of Ne
uirtme rah uAW c,Print m issuance ora CertiEcau or up Signature of Applicant Date
nom mm,i.dagent D.m/ All roof coverings to be Class "B"or better
Community Development
0 Torre Avenue
CupeOrtino CA 95014
Telephone(408)777-3228
CITY 0, Fax(408) 777-3333
�UPEkTINO
Building De I partment
JOB ADDRESS PERMIT #
30
OWNER'S NAME: ( PHO CF o$ — — �kq .6
GENERAL CONTRACTO / L4 I FAX #
I am not using any subcontractors:
ignature Date
Please check applicable subcontractors an complete the f wing information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
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
g Cr
er/Contractor i e ate
-� CITY OF CUPERTINO csz,
� TEMP POWER 7
CUPEkTINO PERMIT APPLICATION FORM
APN #7� l Z o Date:
J �
Building Address: /05 30 ( 12 �ON l� � 6ir�7jy) �-
Owner's Name: / Phone#: 409 -723-6i/
M'es, M/II� Gf-t o
Contractor: MC-Z-- 1Ql 1-f7 6A:)% 7Phone: License#:
Contact: Phone: Cupertino Business License #:
Z- Aek - 86 - o z
Building Permit Info:
Elect Z
Job Description:
add, _C) 44 s&
Residential ] Commercial ❑
Cost of Project:
Qty.
1 c )e Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING