04080117 CITY CDIVISION
BUILDING
PERMIT CONTR CTOR`INFO 1�IATION'�^,'
BUILDING ADDRESS: DBA ELECTRIC INC PERMIT No.04080117
OWNER'S NAME: PERMIT ISSUE DATE
IV Eo SANITARY O OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Lop LICENSED CONTRACTOR DECLARATION ��!lr���aaa
=�G I Mteby B nn iMt I am lithe Bu under and
Prof ss ofs Code. 9(mmmensi is Job DOSCIIpIIOas ���r/m
U with Section]OOU)of DivisiO4 NC Business and Professions Codc,and my license is 1{tJm 'f�tj�y
^�2a in full fnrea,md effect.
jq? License class Lk.X UPGRADE SWITCH GEAR '
K'O Date Conuxtor
< ARmapxT$DECLARATION AUG �L 2004
1 understand my plans shall be used u public DECLARATION
DyU
Licensed Pmfcuinnal yy
=ys
OWNER-BUILDER DECLARATION ®�I�®�rA R
1 herehy atB,m the 1 am exempBUILD from the RATION License Law for the D Its In
p o following meson.(Section RD 1.5,Business and Professions Cade:Any city or county
which requires a permit to ennsuuct.alcor,improve,demolish.or repair any swnux
u"^ prior m its issuance.also tequims the applicant for such permit to File a signed statement
met he is licensed pursuant m lite pravisinm of the Conuwtur's License law(Copper 9 Sq.Ft. Floor Area Valuation
�H$ (commencing with Section 7")of Division J of dm Business and Pmfeuinns Code)or
—
that he is exempt therefrom and the baso for pre alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to A civil penalty of 3 UN�`Y4�ge7 0 0 Occupancy Type
not mom than five hundred dollars($500).
❑I.asovoc,of the property,.,my employe.with wages u their to compensation,
will do Ne work,and the structure is not intended or offered for sale(Sec.1041,Business
and Professions Code:Tbc Convacmrs Lt..Law does trot apply to an owner of Required Inspections
property who builds or imp oveithetrnn.and whodoessuch work himxlfortloough his
awn employees,provided that such improvements are not intended oro@red for sale.IL
howevea the building or improvement is sold within one year of completion.Ne owner,
Wilder will have the burden of praying that he did not build or improve for purpose of
sale.).
❑1.as owner of the property,am exclusively summering with liartsed co.vacmra to
conaracr the project(See.1044,Business and Professions Code:)The Conearxra Li
cents Law docs not apply to an owner of property who builds or improves thereon,and
who mnuacu for such projects with a conuacsor(s)licensed pursuant to Ilse Conuarim's
License Law.
(]I am tic Pro. gee. B&P c for thio roto.
O �
WORKERS COMPENSATION DECON
pl hereby afOno muds,prettily ofperjury oro of owing declarations:
and will maintain a cusifiem,of Comenl to self-maumforWorkeisCompen-
cotion�ae provided fo,by Section 37W of IAB Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Imunna,as required by Section
37M.f NC labor Code,for the ped o....of due work far which this permit is issued.
My Workers Compensation Insurance canner and Policy number arc:
Cartier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crosse ction need nothecompoted it tie permit is(crone hundred dollars($100)
to,Itis.)
I reunify that in due performanec of the work for which this permit is issued,I shall not
employ any person in any manner an a an Accomc subject ra the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.aftr making Nu Cenificate of Exemption,you should
become subject m the Workers Compensation provisions of the Lahr Code.you most
.JO forthwith comply with such provisions of this permit shall he decreed revoked.
zVy CONSrRUCf10N LENDING AGENCY
[-+ I Acraby affirm that them is a conswction lending agency for the performance of
'Y 7 the work for which this permit u issued(Sec.3M.Civ.C.)
lA Q Lender's Name
:D z Lenders Address
U Q I certify Nat 1 have read this application and sate that Be above information is
(L F torten.l agree m comply with all city and county on irmnsum and sone laws relating to
0 U building corearuction,and hereby authorise mprmnotives or this city to enter upon the
r alcove mentioned prapeny for im y an purposes.(We)agree to cove,indemnify end keep harmless the City of Cupertino against r
Uh inconsequencejudgments.cmtsand expenses which may in anyway attstm again.said City I/ O
U z m consequence of the granting of phis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R'^ULA ONS e /
: � Re-roofs
Si coli of Applic UContractof Dole.
HAZARDOUS ATERIAIS DISCLOSURE Type of Roof
Wail the applicant or(retire oilding occupant a are
or handle bavarirms material
az defined by the Cupertino Mu cipal Cade Chapter 9.12.and the Health and Safety
Cede.5c Yea 25532(x)? All roofs shall be inspected nor to an roofing material bei.
_ ❑Yas Nm P P Y g g installed.
Will the applicant or futumlbuilding oceupant use equipment or dcvicm which If a roof is installed without first obtaining an inspection,I agree to remove
hamodous air contaminants defined by the Bay Area Air Quality Managemm all new materials for inspection.
suicR
❑Yes No
I have read the IuaaNnusmamrials mquimmcnu under Chapmr 6.95 of the Califon
nice Health&Safety Code,Secu x.25505,25533 and25534.1 undersand domif tic building
does not currently have a mount,that it u my respomihility to notify the occupant or the
retai nu which mctpriortoismance.r.CcruficaeOf cupem), Signature of Applicant Date
O e,or Date All roof coverings to be Class"B"or better
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