04090229 CITY OF CUPERTINO ' ,'�'�' �`
BUILDING DIVISION PERMIT PCONTRAM— OR INFORMATION
BUILDING ADDRESS: PERMIT NO04090229
04090229
OWNER'S NAME: PERMR ISSUE OATS
ST. JOSEPH
ONE:
SANITARY 90. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
III uo0
LICENSED CONTRACIOR'SDECLARATION Job Description
y C w 1 M¢by affirm that 1 am licensed itder Powsiom^f Chapter 9(commencing
$ml! il ]u(%q of Division3of NC Bus'gC�aa dPro uinne Codc,and my'cents is
2m,,, mmB doff«,. TEMP. POWER
j 2 Li f"11c Iasi Lic.p
CONTRACTOR: R. P .D. ELECTRICAL SERVICE
x� sD ry
e I undcrvan my pia shall umJ as no
lie memds
Oyu
;�G Licensed Professional
3 OWNER-BUILDER DECLARATION
yR 1 hereby affirm met 1 am exempt from the Contractor's License Law for me
i o o following moon.Section 70 21.5,Business and Professions Cedc:Any city Or county
K m which requir a permit Ip construct,alter,impmw,demolish.Or repair any s,rectu¢ -
Ito-mi prior in its issuance,also requires me applicant for such permit to file a signed stammen,
< ma,hes,T,eenudpamuv,ttohepmvisines^rthe connecon•sueenaeLaw(Chapter 9 Sq.Ft. Floor Area Valuatio$ 00
.50 (commencing with Section 7000)of Division 3 of the Business and Pmressioas Colk)or
y Nat he is exempt Osterman and the basis for Ne alleged exemption.Any violation of
Seedon l031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
no,more than five hundred dollars(550).
01,as owner Of the pmpmy.in my employees with wages w their sole compensation, 31626093 . 00
will do the work end the awc rte is no,intended or offered for sok(Sec.1044.Business
and Professions Code:The Conmmor'e Luxe Law does on,apply to an owner of Required Inspections
Own
property who bodies mvi&d that
schimpr andwho=not intended work
croffa m through his
ownver.the
Ding or i prsuchnt is improvements artnot ear of cmOffemd forthe ow.r..
however,the building or improvement is old within one Weld or improve
for the owner
builder will have me burden or proving mat he did no,build or improve for purpose of
salt.). l
1,as awmf of the property,em exclusively convu,ing with licensed convectors to �L
comLa the Pmjen(Sec.]1144,weer of
and ProfessionswhWill
Codei The Contractor's Li \`
come,o c law dors not apply a an with
a of property who drills or improves thereon.and
whoLaw.for such pmjecu with acontnaogs)limned pursuant to the ConvxmYs
0
License am law.
�I am exempt ndcr Sec. .B&P C for this moon
Dees
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury Om of the following declanduv:
I haw and will meimain aCenificau of Covent to self-imum for Winker-COmpen-
sstivn,as provided for by Saban 37M of the labor Code,for the perionuince of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3100 of nor Code,for the performance Or the work for
whichthispermits issued.
Cy We ctaCif C xFl Insurance PrION FROMW Mr RS'
ll.• COMPENSATION INSU
(This section need no,Wcumplcmd if she permit is fmrune hundred dollars($100)
or less.)
1 eenify that in the performance of the work for which this permit is issued.I shall not
employ any pension in any manner an u to become subject to the Workers Contractual
Laws Of Califomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker-Compensation provisions or me labor Cook.you must
.J O furthwim comply with such provisions or this permit shall Inc deemed revoked.
Z"i CONSTRUCTION LENDING AGENCY
[-. Ihereby affirm that lhert is a eoxtmnlnn lending agenry,for the perfmmenac of
C4 the work for which this permit is Wood(Sec.309'/.Civ.C.)
(4]Q Lende's Name
D. lender's Address
U O 1 cenify mat 1 have mad his application and area,that the above information is
tL P correct.I agree to comply with all city and county ordinances and sues laws relating to
0 building construction,and hereby authom,mordenutives of this city to cna,rupnn me
,ra above-mentioned propeny for ixpcction purpmcs. ,
(We)agree in saw,indemnify and keep harmless d¢City of Cupcntno against
F fA liabilidu,judW�Q
is; apcnsea which may in any way acmue against said City
U z APPLIeq TtAN Sin,qf IAIND rmn COMPLY WITH LL NON-POI Issued by: Date /`S.
Re-roofs
coign re of Applicant/4 onhO
HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the applicant Or future building occ tparrt store or handle havardous material
s defined by me Cupertino Municipal Code.Chapter 9.12.and do,Health and Safety
rude.Section 25532(x)? 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
faink
If a roof is installed without firs[obtaining an inspection,I agree to remove
haurdous air contaminants as defined by me Bay Area Air Quality Management all new materials for inspection.
District'
❑Yes
V nu materials rtquimments under Chapesrb.95ofthcCalifnr-
niaHyC .Seed x235(15.25533 and 25534.1 undcrsund this ifthe Wilding
does w a ten 4 that n v ms onsibility to nodtymeOccupantOrthe
mqui ate �ri . xis, ¢4�mcemrr:,L o aper. Signature of Applicant Date
ter ratmnmcdagent Dam All roof coverings to be Class "B"or better
-�, Community Development
r ' 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT # O
lc A2.c> �-I, II� a�lo.C�ti ,exl Q,OI� 02
OWNER'S NAME: Sr, pAe-tS PHONE #
GENERAL CONTRACTOR: FAX #
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
eet Rock
/Ire /Contractor Signature ate
CITY OF CUPERTINO
�2wt�. �p� o � o Z z7
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 / LG Date:
B ildi dress: U
Owne Name: Phone#:
Contt9r: 'G .� rC� License
C t: Phone
Applicant/Contractor:
Building Permit Info:
Bldg Elect - Plumb Mech
Job Description:
Residential: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: tion:
Type of Construction: Occupancy Group:
•
QtY. .
A c e Fee ID Fee Description Fee Group
/ BPERMFEE Bldg Permit Fees BUILIDNG
i
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
7 � W1
I � �L
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BUSLIC Business License BUII,IDNG
z7 1 � 3
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