04030206 ( CIT OOF CUPERTINO � " - ,- sr�• " Fs ;"' '
BUILDING DIVISION PERMIT CONTRACTOR INFORMATeION ;
OUI LDING ADDRESS: PERMIT N0.
04030206
OWNER'S NAME: PERMIT ISSUE DATE
PRANKIE LAW
ONE: SANITARY O AOL NO.
ARCH=1ENGINEER: BUILDING PERMrr INFO
BLDG EL.ECI' PLUMB MECH
i 0 C, LICENSED CON RAl=R'S DECLARATION
1 Mmby affrm Lori I am licensed under provisions of Chapter 9(commencing
lob Description
0with Scnion 90(q)of Division 3 of NC Business and Pro[mmions Code,and my license is
n e in full from and effect.
LieeaeClass Lk.gDate_Comeacier TEMP POWER �qp (� ®�a
ry ARCHITECTS DECLARATION Y®PP�+aa �a�awm
1 undersand my plans shall k used as public records
;w
;in LicensedPafesomi.1 MAR 2 0 2004
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from situ Contramofs License Law(or the
O o following mason.(Section 7031.5,Business and Prefessions Code:Any city or county
m which requires a Permit m cttrstruu,alto,improve.demolish,or repair any mrncwre
F Z y prior or its issuance.ebm mquires the applicant for such Permit to fie a signed stat mem
YG that he is licensed pursuant to the provisions of Ne Contracwfa Liecnse Law(Chapter 9 Sq. Ft. Floor Area V , 10
x€ We
(commencing with Section 7W)of Division 3 of the B urmass and Professions Code)or
i $
that he Is eacrept therefrom and the buss for ds alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjeca the apploled 10 a civil Penalty of 3 AYNRI yg qr 0 0 Occupancy Type
not ream Nan five hundred dollars(SSW).
1,uownuefdapm sexy.mmycmpfoyceswithwagoudxbsmocompenudon,
will do Ne work and fie structure m not intended proffered for sok(Sec.7014.Business
and Professions Code:no ContmcmYa License law does not apply in an owner of Required Inspections
properly who builds riled nonsuch
h inapr andwho dmaamh rokud omaelf fir duough hf.
own a however,
the u.P ing or improvement that such Improv ld wit are not intended mpleti n.for ale.If.
however Ne five orer ofpis sold within one yens of completion,Ne ownco-
builder will have Bethe burden of paving the he did not builder improse for PuryO¢of
vle.).
0 I,as owner of the progeny,am exclusively connecting with licensed connectors to
constmet the project(Sec.7061.Business and Professions Code:)The Comracmr's U.
casae law dors not apply in an owner of propcny who builds or improves thereon,and
who conuacta for such parcels with a contmnor(s)licensed pursuant to the Contractors
L'era's'el¢aw.
I
"et tmolmS .B k P C for Nis re con
Dale
O 1 a DECIARATI
hereby arm under Pcnalt of perjury one f th owing deductions:
1 have and will maintain a CeedOomof Consent to self-insure for Worlmes Compen-
aniov,as provided for by Section 37W of the Labor Code.for the Performance of da
work for which this Permit is issued.
❑1 have and will maintain WmIum-a Compensation laurance,as required by Section
37W of d¢labor Code,for the performance of she work for which this permit is issued.
My Worker's Compensation In...caricr end Policy number are:
Cartier. Policy No.:
CERTIFICATE OF FXEMPr10N FROM WORKERS'
COMPENSATION INSURANCE
rphisseesion recd not Wcompleted Vthe Permit Is fmone hundred dollars(S)W)
or less.)
I certify the,in the prof ner.m,of the work for which this permit is issued.l shall of
employ any person in any manner so as to become abjuuo tic WOnkmi Compenution
Laws of California.Date
Applicant FIE
NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should AR 2 4 2004
become subject to be Workers Compcnsatinin pNvisiOm Of the Labor Code,you must "
.Jforthwith Comply with such Provisions or this permissh.11 bu deemed mm ked.
p(
'z '"" CONSPRUC"nON LENDING AGENCY
Ihereby affirm that then is aConswction lending agency for the Performance of 't�v s----
D: the work for which Nis permit 6 issued(Sec.3097,Co,C.)
V]Q Leader's Name -
lY
Z Lender's Address
a
U O I cerfify that 1 have rod this application and ma that the above information&reis
F' cortem 1 once ct comply with all city and county ordinances Of and Cute hws relating to
OU alwyengcoauuctiomend hereby impttwnpurposes nutisrs of this city menterupnn the
Ck1 aMvo-(We)
a re progeny for i indemnity
an keep z
(We)agree s,save,indemnify and hick harmless the City rat Cupertino against
Fh incosere dgme of l"Ithe costa and expenses
crool. mey in any way accrue against said City
U^z' APPLI�W UNDc S TANDf AND WILL COMPLY WITH ALL NON-POINT Issued by: (teZ��
SOU U I
Re-roofs
HAZn DOUS MATERIALS DISCLOSURE Date Type of Roof
Will thc.,plica or fuwre but occupant store of handle hvANou matuial
u defined by the Cu num Municipal Code.Chapter 9.11.and the Hcailh and Safety
ode,Section 15531(.)? All roofs shall be inspected prior to any roofing material being installed.
�Yps No
Will the applicant or future building occupant use equipment or dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
mit M1araNnus oir contaminanu u dcfncd by thx Bay Ama Air Quality ManaSOmcm all new materials for inspection.
District?
O Ycs //�No
I have real the heard/s materials mquimments under Chapter 6,95 of the Coffer-
his Health A,Sarmy Code.Seeuoa 15505,15533 and 25534.1 undersand thm if the building
Jars mol eta hoc tit is my reaponsibilily b nosily the m'cupant of Ne
regmire n h q_te,ptl r vanceo C C.te.fOccopatey. Signature of Applicant Date
to :x Da All roof coverings to be Class "B"or better
CITY OF CUPERTINO
` TEMP POWER
UPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
n/DCAf 9_S"O/
Owner's Name: Phone #:
N
Contractor: Licerfse#:
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Elect ❑
Job Description:
Residential ❑ Comm' rcial ❑
i
Cost of Project:
Qty. if
Appliol@e Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
aq?37
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