04080111 CITY OF CUPERTINO �" _hVMV
BUILDING DIVISION PERMIT GONTRAGTOR'INF,ORMA.TI,ON:' .
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Bun.DING ADDRESS: NATIONAL CONSTRUCTION REN_J-PERMIT
OW NER'S NAME: PERMIT ISSUE DATE
ONE:
SANITARY N 0 OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
nor, LICENSED CONTRACTOR'S DECLARATION Job Description
X F I hereby affirm that 1 am f ased under provisionsof Chapter 9(commencing p}fig �S
L:iw wim Scctim70010Of Division 3 fgh Busincas and ok s-st Codc,anI my liccnu is I/ ai
in full Tome ain,
effect
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LimnuCm G / D3L1,i d�n , TEMP POWER POLE
ZF, Dam Co lar �LrJ OD
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i l understand my plans shall he cd as public records (a a 4
J a U M
Licensed Pmfcssional B
=�3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from me Contractor's License Law for the ,tl
n 0 following moon.(Section 7031.5,Business and Professions Code:Any city Or county
I
m 0� which mquirea a pmmor to cnnstmtt,alien improve,demolish.Or.,air any smseard
'n—'^ prior to its issuance.also mquires the applicantfor such permit to rile a signed statement
Z a that he is licensed pursuant to the provisionsnf Me Contractor's Limnsc Law(Chapter 9 Sq.Ft. Floor Area Valuation
bio (commencing with Section 7")of Division 3 of the Business and Profusions Code)or
i mal he is exempt therefrom and be basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjmM the applicant to a civil penalty of 3 A819.Mlllhef 00 Occupancy Type
not marc man five hundred dollars($500).
❑I.as Owner mfthe property,or my employees with wages as their sole compenudon,
wIII do the work,and he swnum isnot imended or offered for sale(Sec.)044,Business
and Proectors Professors Code:The ConvLicense Law does not apply m in Owner or Required Inspections
property who builds or improves ftmon,and who does such work himself m though his
own employees,provided mal such improvements are not intended oroffend forays.IL
however,the building or improvement is Sold within one year of mmpledon.me owner.
builder will have dm burden of proving that he did not build or improve for purpose of
Sale.).
❑1.as Owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.9044,Business and Professions Code:)The Contractor's Li-
mand Law does not apply to an owner of property who builds or improves menton,and
who contracts for such projects wit a contoemr(s)licensed pursuant to the Conuactafs
License Law.
❑l am emmptander see. ,B&P C fm dist camp
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 haw and will maintain a Certificate of Consent 0 self-insure for Worker's Comper-
sation,
orkeisCompen-
sation,az provided for by Section 3700 of the Labor Code,for the performance of me
work for which this permit is issued.
ban and will maintain Workcr's Compensation Insurance,as required by section
700 of the Labor Cade,for the performance of the work for which this peon it is issued.
My We, Cn��mp��c�ns�at/iIa/p lnsunq��)c canter and Policy number a¢: q ,
Carrier. �a"a^A•(.4a OVO Policy Nii RJUB 401%OI 7-0.3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
frhissection need not he completed if the permit is formic hundred dollars($100)
or less.)
1 cenify but in the performance of me work for which this permit is issued,I shall net
employ any person in any mannerso az to become subject o the Workers'Compensation
Laws of California.On
Applicant
NOTICE TO APPLICANT:IL after making this Cenificav of Exemption,you should
become subject to the Worker's Compensation previsions of me Lahm Code,you must
2 forthwith comply with such provisions or this permit shall W deemed ranked.
QCONSTRUCTION LENDING AGENCY
E•+ l hereby affirm that them is a construction lending agency for the performance of
C;1 the work for which oris permit is issued(Sec.3097,Civ.C.)
(y Lender's Name
Lender's Address
U O I certify mat I have read this application and state mal the above infomudi n is
U. F correct.1 agree to comply with all city and county ordinances and sum laws relating m
0U building construction.and hereby authoma representatives of this city to enter upon me
r LL1 abovomcrommed property for inspection purposes.
,� gy (We)agree to save,indemnify and keep harmless the City of Cupertino against
N
Liabilities,judgments,costs and expenses which may in any way Stere against said City
UZin consequence ofthe granting afthis mI I/
^ APPLICANT ERSTA S WILL C PLY WITH ALL ON-POINT Issued by: Date
SOURCER LLAAT�IOq
Re-roofs
signawrc ol'AppitradUConourannor Data
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumes building occupant score or handle hazardous mamrial
az dcfmcd by me Cupertino Municipal Code.Chapter 9.12.and the Health and safety
Cade.Section M532(a)? o+� All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous it mnuminaneaz defied h me Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑ u
1 have mm
ad the hazardous amrialstagnmmcnts under Chapter 6.95 mthe C ofm-
niaHealth&Safety Cade,Sections 25505,25533 and 25534.1 understand mi building
does not cunend have a moan.ma it is ay responxihilhy m not.IY the nempant of the
mipimment,whylyanS ain
sypl; aanttnr cnifeaLcmrOcmpanty. Signature of Applicant Date
Owner mrOr nomlzed agent Date All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
fTY
o Cupertino CA 95014
Telephone(408)777-3228
F Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #6 6
2-2-z110
OWNER'S NAME: PHONE # 30 'j -G3?-4Y
GENERAL CONTRACTOR AX #
I am not using any subcontractors: l3 0
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
,3 0
OWher/ Signature Date
CITY OF CUPERTINO C
TEMP POWERCITY OF
CUPERTINO PERMIT APPLICATION FORM
APN # �� Date: P113
Building Address2 2 Z / p I`O1
!o
Owner's Nam t Phone#:
���_¢ _ 309-039-81
Co actor: one: License#:
28,0-1.700 (c $7 t 6 0
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Descr' tion:
lo ilry o
Residential Commercial ❑
Cost of Project: �o
OD
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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