05040174 CITY OF CUPEW11NO r ,'.
BUILDING DIVISION PERMIT. CONTRACTOR,INF®RMATION
BuIMINGADDRESS: HBDT CONSTRUCTION, INC. PERMITNO.05040174
546 DECT)ARA DR
OW HER'S NAME: PERMIT ISSUE DATE
N@
SANITARY 4 O §OL NO,
ARCIIITECT/ENGINHEH: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEM
0 0
Lap LICENSED CONTRACTOR'S DECLARATION
UZ F 1 humby,frrm that I am licensed under provisions of Chapter 9(commencing Job Description
n< with Section 70M))of Division 3 of the Busineasand Professions COO,and my license is
s in full force and effect.
on— 'C Rax clue LIG.a TEMP POWER
Z g' Date Comremor
? 'af` ARCHITECTS DECLARATION
U I understand my plana shall he used as public records
W GLicensed Pro cssinnal
OSS OWNER-BUILDER DECLARATION
iy 1 hereby affirm that I am exempt from the Contractor's License Law for the
n 0 following mason.(Becton 7(131.5,Business and Pndessinns Code:Any city mf county
$ which reciAres a permit to Construct,alter,improve,demolish,or repair any structure
prior W its issuance,also requiMS the applicant for such permit to file a signed statement
that he is licensed pursuant to the pmvismns of the Convector's License Law(Chapter 9 Sq.Ft.Floor Area Valuatio
�$ (commencing with Section MR)of Division 3 of the Business and Pforessinns Core)or
_ Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 L5 by any applicant for a Permit ubjects the applicanuo a civil penalty Of 3 G1Y4rS�fOO Occupancy Type
not more then five hundred dollars(55(10).
1,as owner o(the property,urns em ces with woes ss their sole compensation.
❑ t act Y pended 8 pen
will do Poshework,and theswetoeis roti Licensoroffends forsaleto an wateBusr of "'
ss
end Professions Code:lTc Contractor's License Law docs not apply lf,n owner of Required Inspections
propenywyCOa,pdovided xovnd¢st such improw who doe ssuchworkhimxlfor through hisovo
ncmPlnyecs,p building
or improvement
mrovememprowmenta within
ne you tlWmpeered for owner.
however,the building or impmwm<sn is sold within one year of completion,for
the owner
builder will neve the burden of proving Net he did not build or improve fur puryou of /Q
ask.). 13y
(5p 1.as owner of the property,em exclusively contracting wish licensed ermummrs m
E9T tmet the Pmjocl(Sec.70416,Business and Professions Code:)The Contractor's Li. �_- ✓
cense Taw docs not apply to an owner of propeny who builds or improves themon,and
who contracts for such projects with a c^nvacmf(s)licensed pursuant o the Convenors ! ,l
License Law.
❑ Iam'ama tunder See. B A,P C for his reason
Owner Da¢ Z
RKER'S C11t31P NSATION DECLARATION
1 hereby emfro under peon 1 of perjury one of the following declantions:
1 have and Will maintain•Cenificam of Consent to self-insure for Worker's Compen-
sation.as provided for by Section 37M of the labor Code.for the pertormanm of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insunnee,as rtquiMd by Section
37M of me labor Code.for the pertormance of the work for which this permit is issued.
My Workers Compensation Insurance Cartier and Policy number aa:
Camcr. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the Permit B for one hundred dollars(SIM)
less)
1 eeni(y Nat in the performance of Oc work for which this permit is Issued.I shall not
employ any person in any men^$�s ea exbjee mdse Workeri Compensation
Laws of California.DateL —
Applicant _' �—
NOTICE TO APPLICANT:IL after making this C 9ficate of y mption,you should
become subject to the Wohni C^mpcnRation. atomofd LiWrCMe,youmust
.J O forthwith comply with such provisions of this permit shall he deemed revoked.
'Z' CONSTRUCTION LENDING AGENCY
I hereby alBfm that mere is a Conswction lending agency Or the performance of
(Y,> the work for which this permit Is issued(See.3W7,civ.C.)
!y 0 Is rk,',Name
z Le dcrs Addmss
U O 1 Certify mat I have reed this application and x duthat the above information is /
torten.1 gree x comply With all city and county ordinances neGs and sox lawswsoclrelating to
0 building construction,and hereby authorize representatives of this city to enter upon the
W above mentioned property for inspection purposes.
(We)agree to Rave,indcomfy,ad keep hsrmless the City of Cupenino against
liabilities,judgments,costs and expenses which may in any way seeuc against said City
U inconsequence of the granting of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULA NS.
/2?L� Re-roofs
Signator ofAocan�n r Dam
I3AZA DO MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle havardous material
Radefined by the Cuptomn Municipal Code.Chapter 9.12,and the Health and Safely
ode.BeC]yes pp nyon 25532(a)? KIN. All roofs shall be inspected prior to any roofing material being installed.
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
7M/
it haxerdnua air contaminants as defined by the Bay Arca Air Quality Management all new materials for Inspection.
wrict? �
C3 Yes WNu
I have mad the hamrtlous materials requirements under Chapter 6,95 of be Caldor.
.in Hcal sh&Safety Code,Sectors 25505.25533 Rod 25536.1 understand the Vote Wilding
es not COMM),have a x^ant,that it is my resbensibiliy x hotly the sexupent of the
quihmathcmmnor... nrriCemneaxnra<pan(pfr. Signature of Applicant Date
1OJ All roof coverings to be Class"B"or better
t Tired egcm Dmc
aoev_, �
CITY OF CUPERTINO
TEMP POWER
Y OF
UPEkTINO PERMIT APPLICATION FORM
mar APN # t _ 3 Date: Z� 7Zo S
Building Address:
Owner's Name: Phone #:
M; - Jen Ts - - 6D /
Contractor: n -I- S� c Phone: Zu License #: � Z 36 23
Contact: jq� a� Ola rt Phone: kg_ b o 3 —66 6 3 Cupertino Busi6 4,Lness License#:
Building Permit Info:
Elect N.
Job Description:
Residential Commercial
Cost of Project: y� (2-0
Qty. if
Applicable Fee ID Fee Description Fee Group '
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING