03100045 COPY OF CUPEW11NO
BUILDING DIVISIONPE RMIT CONTRACTOR INFORMATION &!
BUILDING ADDRIiSS: FRAN LEE CONSTRUCTION INC PERMIT NO 03100045
OWNER'S NAME: 10935 MIRAMONTE RD PERMIT ISSUE DATE
SNE:
(408) 996-2527 SANITARY NO, CONTROL NO,
ARCI HTEC fENGINECR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
=1boa LICENSED CONTRACTOR'S DECLARATION
•mp I hereby affirm that l am licensed and.,provisions of Chapter 9(e mmine. Job Description
�aW with Sccrion) ))nf Divixion3 of the Busin�snpd Prurnsum,Code.and mylicensc is
m fullfomc efmct •�V_�o TEMP POWER PERMIT
Licensee s Com l
i F Date Cusum -
A HITECI'S DE RATION 11/
u I understand my plans shall he used as public record, O
y Licensed Professional v
•p< OWNER-BUILDER DECLARATION
<qq 1 hereby affirm that 1 am exempt from the Contractors License Law for the
00 following mason.(Section 7031.5.Business and Profe.axions Code:Any city or county
5 which m4uires A permit m ennxtrueL ales..improve,demolush,or¢parr,any structure
.ai prior in its issuance.also requires the applicant for such Nornil to rile a xignedsutcmcm
2s0 Ihalheisliccmsedpi
...notInthepmvirimaoftheCmarselorLicenseLow(Chapter9 Sq. Ft. Floor Area Valuation
21- (commencing with Section 7s00)of Division Sof lM Business and Pmreniom Code)or
!i that he is exempt therefrom and the baso for the alleged exemption.Any violation of 35918015 . 0
Section 7031.5 by any applicant for a pennitsubjects the applicant to a civil Penally of ccu ane APN Number OType
net mare man five hundred dollars(ssuo). Occupancy YP
❑I.as owner of the Property,or my employees with wages ak their sole compensation,
will do the work.andthe swnure is not intended of offered for sale(Sm.7044,Business 103 - UFER
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his 304 - ROUGH ELECTRICAL
own employees,provided that such improvements An not intended or offered for sale.IL
however.the building or Improvement is sold within one year of completion,the owncr-
builder ,will have the burden of proving that he did not build or improve for purpose or
sale.).
O 1.as owner of the property,am exclusively contracting with licensed contraction to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li.
corse law docs not apply to an owner of property who builds or improves thereon.and
who contracts for such projects with a conrnntogs)licensed pursuanno the Comment's
License Law.
O l amcxemPrund..S". ,B&PCforrhisscamn
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following daoratio an
I have and will maintain A Certifies.of Consent to self-insure for Worker's Confirm.
Asian.u prvvidcd for by Section 37M of the tabor Code.far the pufmmance of for
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,a required by Section
3700 ofd.labor Cede,for the Performance or me work for which this permit is issu d.
My Worker's mpen lion Insurance artier and Po icy number art:
Cam:rC/ — 12
��JJ"- CERTIFICATOF E%EM FROM WORKER
COMPENSATION NSURANCE
(This section need not M completed if the permit is for one hundred dollars IS 100)
or less.)
I certify that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner ants m become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,aper making this Cerireau or Exemption,you should
become subject to the Worker's Com P.neation provisions of the tabor Code,you must
z foMwilh comply with such Prrvisirm or this Permit shall he deemed revoked.
LO CONSTRUCTION LENDING AGENCY
I hereby of on,that then is a construction lending agency fm the Performance of
X de work for which this permit is issued(Side.307,Civ.C.)
I]A Lenders Name --
Lenders Address
Z) z
Q 1 certify that I haw read this application and state that the above information is
L F' conch.1 agmc to comply with all city and county ordismnms and state laws hitting to
V building convection,and hereby authome repreuntatives of this city to crier upon the
LU shove-mentioned property for inspection purposes.
•y gy (We)agree to saw,indemnify and keep harmless the City Of Cupertino against
h Habilidea,Judgments.costs and expenses which may in any way¢cmc agaimtseto City QQQ
J z in consequence of the grams,of this permit.
'—' APANT UNDERSTANDS AND WILL COMPLY WITH ALL .POINT Issued by: Date
SOU E.R U ATIO
o Re-roofs
Signature o tic HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
ill dM applicant or tutu..building recto ml nom or Ns insured,
handle havaou
As coed by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
cr e.seeeen 25532(.)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
o
Will the Ilcml or future building occu art naa a If a roof is installed without first obtaining an inspection,I agree to remove
nn s v equipment or devices which g P
7ni,H.)
baa.dous air mitumimnu .fined by the Bay Arca Air Quality Management all new materials for inspection.
ic
❑Yids. Nu
1 have mad de hanAnd us materials requirements under Chapur6.95 orde Califon
odcrunot ly haw A um.rd.oar itis my rcarr nsihility to nutty d¢mcupmrl of de
reare n arse metpderh,ie.kne.nfaccrdr oar prOc.vp y Signature of Applicant Date
crura H.edapent ,m All roof coverings to be Class "B"or better
r
CITY OF CUPERTINO O 51046
�az TEMP POWER
UPEkTiNO PERMIT APPLICATION FORM
APN # � /r � =Dale*:
Building Address:
058, 3 W
Owner's Name: Phone #:
h �' ��� � C'�6� g6 - 00-�PV ,42
Contr or: U Phone: License#:
Fyn v, LeA C-0 vi 5 tKIA -hko 0 a3 q 3 e
Contact: Phone: Cupertino Business License#:
A Y — S,0-e-
Buildiinng PPermit Info:
Elect E]
Job IT Description:
e1� w4, 2
Residential Commercial ❑
Cost of Project:
Qty. i
A l 1 Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING