05010026 CITY OF CUPEW11NO sn 0r Pa :.:. •xs .+ .„
HUILIYNG DIVISION PERMIT CON, ItAC1 ORANEORMATION a
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BUILDING ADDRESS: FARRIS ELECTRIC INC DERMrrNO.05010026
12ERIINc) RD
OWNER'S NAME: PERMIT ISSUE DATE
SUNNY VIEW LLTT14F.RAN HnMF R-�4 ITIRY CT 43
SANITARY NO. CONTROL NO.
(408) 287-1327
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
10, LICENSED CONTRACTOR'S ECLARATION
mp 1 hereby affirm that 1 am I= dcr vi9ons of Chapaer 9(cammencing Job Description
�<W with Sec 7 yuf Divisiion30the Busln anEPmfessi s Cnde,end myliceneeis
�y
in fee der 4REPLACE BREAKERS
ja�Z Lscn Co.N 1
r o Da Cu
qq ARCHITECTS EA A I
1 undcrsmnJ my plans shall he fee a public ON
7yUy.
ebb
Licensed Prvfcssione)
5 OWNER-BUILDER DECLARATION
ay 1 hereby affirm Nal 1 am exempt from the Conuamofs License Law far the
20 following rmsan.(Section 7131.5,Business and PmMsviana Code:Any city or coun,y
='n which requires a permit to construe,alter,improve,demolish,or repair any structure
u_a pnor w its issuane4Se rtqui¢s the applicant fdrsuch parsaiii.Glaasignedstrement -
< tnatheiarcensedpursuant tothe provisions ofthe Contractor.LiceneLaw(cnaper9 Sq.Ft. Floor Area Valuation
erD (commencing with Section AW) Division of the Business and Professions Chile)it
$ that he is exempt therefrom and the Esso for the alleged exemption.Any violation of wr s.
Section 7071.5 by any applicant for apsmal subjects arc applicant ao a civil penalty of 32�WM2l4er00 Occupancy Type
not mare than Bias hundred dollars(2500).
I,as owner of the inolent,n my employees with wages as their sole compensation,
will Jo the work.and the structure is not intended or offered for sale(Sec.7014,Business
and Professions Code:The Con,nctori License Law docs not apply to an owner of 17�yquired Inspections
Owncnywho yees,provided
dmrid that uchimprantlwho does dost ch wort oroffend far ugh Sale,
20 n �21I
howempldyem,ping oritnuvementps soldwthinne intended oroRend for salt.lr, Itlr"' I//,��,`\1 {E IIIAc
however.Ncavetiebrimpmprovinishatbe ii not build or
rcompvtior the owe or
builticr will have the burden of proving Net he did not mild m improve or purpose of
sale.). �.y
❑1,ru Owner of me pm.7(A,.B eaesivnd confessions with:)The
Contractor's
to JAN !- 2005
Construct a the project(Scc.to a n.Business end Professions Code:)The Conuacm(s tad
who conwducsr Such not plyman with
3COof prvpeny whoWildsto
Contractor's
,
was sam exempt user projects wileacpnuacmr(s)licenedpursuantto d¢r thisason BK
11 ® ISS
License Law. t�IrrU1L[11111�t1/II ��`aUV�I�/\/\�T�J—/
❑ I am caemDt under Sec. .B h P C for this reazon
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penelly of perjury one of the following dalaratiom:
U ve and will maintain a Cenifcate of Consent to elf-asure for WorkersCompen-
737M
n,u provided for by Section 3700 of the Labor Coda.for Ne performance of the
for which Be,permit is issued.
nave a d will maintain Wohcr's Compensation Insurance,az required by Section
of Ne Lor Cole.for the performanccofthe work far which this permitis issue].
ork Cnmpe lion 1 unncortinendPolicy nu Mraae 'I ,�/>nfOR� Ct
CERTIFI A O E EM OM WORKERS'
COMPENSATION INSURANCE
(Thisscctian decd oat be cwnplcred if the remit is forme hundred dmlars(1100)
or Mae.)
I certify that in the pinfamiance of the work for which this permit is issued.1 shall not
employ any person in any manner so as at become subjml to the Workers'Com sensmion
Laws of Ceifomia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Co.pcnsatlon provisions of the Labor Cnde,you mus,
�7 forthwith comply with such provisions or this permit shall be dccmcd evoked. -
z O CONSTRUCTION LENDING AGENCY
I hereby affirm that Nem is a construction lending agency for the performance of
x ti ,he work for which this pmm'n is issued(Sec.3(197.Civ.C.)
11 Q 4ndeh AdNaress
do
7 z Lender's d -
J O 1 Chad y Nu 1 ban mad this application and Sue that he above information is
1. F Correct.1 agree to comply with all city and county ordinances and Shim laws relating to
Vbuilding consuatb
ction,and hereby sumim e
mprcnuti`es of this city to enter upon the
U5 abovementioned prolreny for impecdon proposes.
WC)agree to save,indemnify and keep harmless the City ar Cupertino against
y
Liabilities,judgment.casts and expenses which may in any way theme against said City
JZ in consequent or the granting of this permit.
^a APPLIC Ni UNDER ANDS ND WILL COMPLY WITH ALL NON-P NT Issued by: Date
50 RC REOULA N
Re-roofs
Igoe c fApp ca HAZARDOUS MATERIALS DISCLOSURE Uelc Type of Roof
Will arc applicant or future building Occupant store or handle hanmous maa:nal
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
code,Section 25532(a)7
❑YAll roofs shall be inspected prior to any roofing material being installed.
u
Will are applicant or ffuture_buildingOccupant use equipment or devices which
a roof is installed without first obtaining an inspection,I agree to remove
na'smaus air contaminant az defined by the Bay Area Air Quality Management - all new materials for inspection.
tuict7
❑res
IhavcmaJ drys ciuusm�atorialsmquim=ntunJ rChapwr695of,he Califor.
nice HcatN&Safety CuJc.Sccaom 25x05.215]7 and Iss3n.1 un,krsmnd,hwif,hc building
acv no ourtend haw:a tenant.Nu it is my responsibili,y In hoary the Occupant of the
regal cntwmc stM ctpnorwimaan¢a(ac[nifaamarlXcapancy � Signature of Applicant Date
f z All roof coverings to be Class"B" or better