02100187 CITY OF CUPERTINO
BUILDING DIVISION PEART ONTRACTOR"INP ION:,,
BUIQP@'(2*1RUW DE ANZABLVD ANDERSON SIGNS PERMIT NO 2100187
OwrgtWKETEER 120 S BECKMAN APPLICATITVYBTKo1112002
HONE: %(209) 365-6203 SANITARY NO. ����TT CONTROL NO,
ARCHITECrfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p00 LICENSED CONTRACTOR'S DECLARATION O
1 hereby)afftrm Nu I am licensed under provhiom of Chepnr 9(commeceingaC ��gppp�L
withSecday7gW)ofoivhion3otthe8 nen and Proressmnscale.ana myhanuh SIGN--ILEUM WA L $
O in fullfnrte tlertectp^ O �p RETREFIT MONUMMENTS
LIZ Lkense
FmJ '-/ "1 ,�RCNITECI'9�I.ARA II V't ml�®
��� lunders�ndmyppnsenellbeuu0eapuhl¢recnma JAN 22
LL o
Licensed Professional 2003
OWNER-BUILDER DECLARATION
u� y I haeby affirm that I am exempt from the Convacto's License law for the
00 following following nuon.(Section 7031,5.Business and Professimns Cale:Any city or county BUILDING
'y �
f 2 61 construct.which requires a permit construct.alter,improve,demolish,or repair any mucmre U LD' G. $10800
s-Z1s poor to its issuance,oho inquires the applicant for such permit to file a signed statement
G that he is licensed pursuant mshe pmvitiomofthe Contractors Liam Law(Chapter 9 Sq.Ft. Floor Area Valuation
,Sq�
(commeoin&with Section 7000)of Diviaion 3 of the Business and Profusions Code)or 32634070 . 00
3 M that be u exempt therafrom and the huh for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjau the applicant to a civil penalty of APN Number Occupancy
not more thmfiinhundred doll.(5500). 101 - FOUNDATION Type
❑I,u owner of the property,or my employees with wages u Neo ule compensation,
will do the work,and the structure is not intended or offend for sale(See.7040,Business
and Professions Code:The Contracuh Licenu law does not apply to an mane,of 104 - RE BAR Required Inspections
property who buildsorimprov thereon.and!whodossuch work himselforthrough his
own employees,provided that such improvements am not ntended oroffeted for We.If, 105 — ANCHOR BOLTS
however.the building or Improvement is sold within one year ofcompleion,the owner- 3O4 — ROUGH ELECTRICAL
builder will have the burden of proving Wt he did not Wild or improve for purpose of
"le) 505 - FINAL ELECTRICAL
❑I.as owner of the property,am excluively connecting with licensed convectors to 514 - FINAL PUBLIC WORKS
comma the project(Sec.7000,Bnsinesi and Professions Code:)The Contractor's Li.
cause law dors not apply to an owner of property,who Wilde or improv thereon,and
who contracts for such projects with a connutor(O licensed pursuant to the Comnaurs
LicenseLaw.
❑lamaxereptunda Sec. ,Bk PCforthismuon
Owner Data
WORKER'S COMPENSATION DECLARATION
41 1 hereby aRrm under penalty of perjury one of the following decimations:
❑Ihave and will maintain aCeniRnnofConanttoUlf-fireman fwWmtCompen-
ulion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I haus and will mqn Wn Worker's Compensation InuruKe,as required by Serum
3700 of the LOWr Code,for the performance of the work for which this permit is issued.
My Workels peni�onn Insurance eartiar and Polity number me:
y
Cartier. Vlb•TEO Polity rFPJd� �RK ' UMII
CERTIFIC OMPEN ATIONl y N WORKERS' Ram
COMPENSATIONI NCE
(7)IISCellon=dnolWwmplee ifftpcmillsfofomhul ddollars(51W)
nrlen.)
I aAfy that in the performance of the work for which this permit is issad,l"I not
employ any person in any manner an u to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:1L after making this CeniOcata of Exemption,you should
become mbjecl to IW worka s Compensation provisions of the labor Code,you most
Oz foMwidtcomplywithaucbproviaiou orthta permiuhsilWMcmcd rtvnked.
z try CONSTRUCTION LENDING AGENCY
F IhenbyalOrm Nat there isacotutmcunn leMin{ageoy for the performance of
ai the work for which this permit is issued(So.3097,Civ.C.)
111 Q LendcM1 Name
z I<nder. Address
C)Q I unify Nat I have read this application and state that the above information is
0 H burten.l ague to comply with all city and county ordinances and sues laws relating e
QU abon-gcodmmctionand hereby authorinmoses. Lives of this city toenurupnn the
W above-menuooedproperty
nest fond expenses
whiphma
L>, (We)agree to save,indemnify and keep harmless the City of Cupertino against
py Iia consequence env,costsandexpenses which may In any say eccrvc against mid City / / �1-
()7
in of the UNDERSTANDS
of Otis D WILL
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINF Issued by: Date
SOUR✓ u
Re-roofs
Armature uofApPlicsoVConO
HAZARDOUS MATERIALS DISCLOSURE Type Type of Roof
Will ties applicant or Tulare Wilding occur mt morem handle huudous maudal
as daBMd by the CnpRRno unicipsl Code.Chapter 9.12,and the Health and Safely
Code.Section 25512(a) All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
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
emit hanrdous sir ccumeno ta u dctincd by Ne Bry Arta Air Quality Msoagcmem all new materials for inspection.
District,
❑Yu
In
so havread Ne huaNrms mauriah mquiremcnu under Cluptor tl.95 of the Califm-
niaHcalth&$afcty Cotic,Sotions25N)5,25573 and 25534.1 unMrstand thati(thc Wilding
dos not cunend have•Imam.that it Is my responsibility to of,the occupant of the
quire emawh to to i0kmimuanceoface ateor`D��., Signature of Applicant Date
Ovorarnauthodral. rM -� D,/pZ, All roof coverings to be Class"B"or better
C CITY OF CUPERTINO SIGN 02,1 C
o
• CUPERTINO PERMIT APPLICATION FORM
APN# 3ZC 34 07
9 Date: ID (S o2
Building Address: 10 20( Qa
Owner's Name: 0.f Phone
Dazs) bqz - 0054
Contractor: Qn66,Ms, Sir
License#:
Contact: , � vTvk Phone
A qzs 6g7--o0s+-
Applicant/Contractor: A I Ovw
Bul ' g Permit Info:
Bld Elect Plumb Mech
Description:
Residential: Commercial: It d ifwwPww�S ( �It
Sq.Ft. Floor Area: $/Sq.Ft.: it ahLiltrm 5"(
0 "
Architect/Engineer: Valuation: I ,gam
Type of Construction: Occupancy Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BPERMFEE Bldg Permit Fees . BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmdl Sings,Marquee ELECTRICAL
BUSLIC Business License BUILIDNG
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