06020163 ;",,ELDING
ITYOFCUPERTINO °'s�sk=awl
BUILDING DIVISION PERMITCONTReC;TURNFORM ATION , ;
lIADDRESS: SANTA CLARA VALLEY CORP PERMNO.06020163
0684 CULBERTSON
ER'S NAME: PERMITISSUEDATE
SUZANNE PIGULA 715 N 1ST STREET 27 02/28/2006
NE: SANITARY NO. CONTROL NO.
(408) 947-1100
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
o I�
30o
LICENSED CONTRACTORS DECLARATION ]obDescri tion
1 hemley affirm that I am licensed under provisions of Chapter 9(commencing P
with Section 7010)of Division 3 of the Business and Profusions Code,and my license is /+}T �
ap inmRmmeanderc I. 6 TEMP POWER POLE ��� �,'!i�'�!('
j�,Z, In U l Clne�Lk.N �e y �`i
7 Date AsmailkTSDELLA ATIO 2006
5 I understand my plain CH W used u public records l sl
5 end Licensed Profasaonsl
OWNER-BUILDER DECLARATION n
I hereby.(Sere on I em exempt from the fession Co License Lew for the :Q "4
O O fallowing maws(section 71nsru Business,a1mr. and w.de ons Calc:My city at county i'I II J� $800 0 0
z P which mquIssuance.•permit re conatmcL alar.hnpmsu h penllllt rie.sir any ummero ) I I� L-/� u ��"11
z�' metheprior to sl ensedpako requires theapplicantof larsthe CohpermitwficomLaw(Cha mens
< Iholmuncing wJ pursuant of Division 3 of tell usinessand Professions
(Chapter Sq.Ft. Floor Area Valuation
$ man a is
r p, sectionrom a d of Divisional of the aged a amps on.My
haia.of
lost W ts axnmpt therefrom seed the baso for los alleged armption.My Hohtion of
Section 7D31.5 by any applicant for a permit subjects the applicant o a civil penalty of r Uu Occupancy Type
not nae man Rve hundred dollars
❑1,umnerofthepmpeny,ormyemploymwlthwaguutheirmlewmpematlon.
will do the work.and the structure ltnotimended oro@red mrsale(Sec.7044,Business Required Inspections
and Pmfudon Code:The Contractor',Limas law don e ns not apply 10 an Owner of q P
property w ho builds or Lmpne w.s dmrcon,and who does mch mark M mal f or tiuough his
Own employees,provided Nat such improvements am notinknded aroRered forsak.if,
however,tits building or improvement is sold within one year of completion,the owtrcr-
builder will have the burden of proving lost he did not Mid or Improve for purpose of
ah.).
Q 1,a Owner of the property,am exclusivcly contracting with licensed comracmn w
construct the pmjm(Sec.7046,Business and Profusion Cade)The Contractors Li.
me law docs act apply as an owner of Property who Wilds or improves themon,and
who contracts for such pmjeets with a commusur(O accrued pursuant to the Contractors
License Law.
❑lamesemptunder Sec .B&PCfarthlsmaon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury aro of the following decimation:
I have and will reacts).a CerORuk of Consent to se161nsum far Workers Comp m-
radon,uprovided fm by Section 3]00 of the Labor Dme,for to performance of the
work for which this permit it issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code.for the performance of the work for which this Permit Is issued.
My Wmke sCompensation Ins.an ter and Policynumber art:
Carter:Ael Ve i Pea Policy NO.:
CERTIFICATE OF EXEMPTION FROM RS'
COMPENSATION INSURANCE
(lTbmction need not beCompleted If the permit Is forms hundmAdollan(SIM)
or kaa)
I certify that In the performance of Ne work for which this Permit is Issued.I shall not
employ any peown in any manner an u m become subject to tiro Worlsri Compensndon
Laws of Calif orI&Dam
Applicant
NOTICE TO APPLICANT:If,after malting this Certificate of Exemption,you should
become subject m the Worker's Compensation prevision of loo Lobar Cade,you must
.,O forthwith comply with such provision m this permit Nal be deemed invoked.
Z CONSTRUCTION LENDING AGENCY
E44 1 W reby aRrm loss Nem lana coatructme,lending agency forlbe performance of
t7 the work for which this Permit is Issued(Sec.3097,Civ,C.)
0 Lenders Name ,
D z Lcrders Addrost
U Q 1 oertlfy Nu 1 have mad this application atm state that the shove information is
IT.F colonel.I qme to amply with all city and county Ordinances and slaw laws mlating to
0r building conatraction,and hemby author=representatives of this city an enter upon the
[T7 mo--n enumaxi properly for inspection purposes
LL (We)agree w aw,indemnify and keep harmless Dm City of Cupertino against
rA ImbllWea,)udgments,costs and experesu which may in any way emus against said City
t.)7 in consequence of The gaming of this permit.
r—r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 'L ZV G
souacBg�E/�{gTONI s Z� py Re-roofs "
Signature rApp112knX oeuac Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupentsmm orhandlc havasdon materia
as dented by dm Cupertino Municipal Code.Chapter 9.13;and the Health and Safety
ode,Section 255320)?
[3 Y. i$�No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equipment or devims which If a roof is installed without first obtaining an inspection,I agree to remove
¢hazardous air comanninanla as dcased by dm Bay Ama Air Quality Management all new materials for inspection.
District?
❑Yes No
1 haw mad the hazardousssmucrlah mquucmemsuntkrChapwr 6.95Of t e Califon
nia Heal &SafelYCodc.Sectiats25505,25533 and 35534.1 understood dnifthc Wilding
does not eunemly hew a moan lost it ts my responsibility to notify LW oceuPant of me
mgaircmc ucbm�Cmet' priaAtbwaecaaracemncemorocaSignature of Applicant Date
•``YCQ_- �[7A'L��— 2—rpany. All roof coverings to be Class"B"or better
Owner or amhmixed a ent pale
' Community Development
10300 Torre Avenue
aClOF
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
9-UPEkTINO
Building De artment
JOB ADDRESS: PERMIT#
XX I 602a �3
OWNER'S NAME: Su Z ,, PHONE # `/o Y —//oo
GENERAL CONTRACTOR: S _, Q.,re, Val/ QCor . FAX # o 2-
I
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 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
Owner/Contractor ignature Date
� � CITY OF CUPERTINO
In TEMP POWER
j
CUPEkTINO' PERMIT APPLICATION FORM
APN # Date:
Building Address:
6 o lk-
Owner's N e: Phone #:
Contractor: Phone: Lice�yse #:
K Ua O&^ - /loo C� S Fr K
Contact: f Phone: Cu K.
Business License#:
V �l n ib o — - zl 2 � .yam
Building Permit Inf :
Elect
Job Description:
Residential Commercial ❑
Cost of ProjectC7()
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
/ EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING