03110130 FLB�UIILD0INGI'PY Ob'COPER'fINO ' `A
BUILDING DIVISION PERMIT �COO NTRACTOR INFORMATIO
ADDRESS:: R K ELECTRIC INC PERMITNO03110130
181 FINCH AV
:R'S NAME: PERMIT ISSUE DATE
:THEL LUTHERAN CHURCH 42021 FREMONT BLVD 11/21/2003
NE: SANITARY NO, CONTROL NO.
(510) 770-5660
ARCHTTECTIENGINCER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
+00 LICENSED CONTRACTOR'S DECLARATION O O O
W 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
�ito with Section 70X))Cf Division 3 drift,II.So and Professions Cndc,and my license is
In full fid c doff Jar p LIGHTING
,�Z Licer.ox ��t� Lic.p_
�F ea Dam Conl Id
IIIILCT*nZ§ R D
E iia d mnJ my plans shall W nod as public records
,,u
C C.O N
LiccvcJ
S WNER-BUILDER DECLARATION
ap hcrchy amrm t at I am exempt from the Contractor's License Law for the
a o following masher.(Section 7031.5.Business and Pmresslons Code:Any city or county
``e m which requires a Permit to Conswa,aper,improve,demolish,or repair any structure 12 5 0 0 0
Ciy priori its issuance,also myuires the applicant for such permit to rile a signed statement
< that he is Licensed pursuant in the provisions of the Cdntnctor'sLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
QFC (commencing wi Or Section 7000)of Division 3 or the Business and Professions Code)or
i $ Nat he is exempt themfmm and the basis for the alleged exemption.Any viNmlon of
Section 7031.5 by asry Applicant for a permit subjects the applicant to a civil Penally of Or OCCU
not more roan rive hundred dollars($50(f). ane). p Occupancy Type
o I.az Owner or Ne pmpem,or my employees with wages As lied sole a Onpevalm , aM Blk n
will do the work.and Ne suucmm is not inunded or offered for sale(Sec.7041,Businessssn. n'
Old Professions Code:The COnuedori License,Law tracer not apply to an owner of Regmr/edl r,I,Z rens
,.,.y who builds m improvea IWreon,and who deessuch work himself dr through his ALJ
Own employee,provided that such improvements arc not intended or offered for aale.If. AUG �QO
however,the building or improvement is sold within one year of completion.Nfie owner-
builder will have tae burden of proving dor be did not Wild or improv for purpose of
salt.). p
❑ L as owner of ct property,am exclusively and contracting with licensed cnnuecmrs i �Bp ®Bp•�
ccoswnthe prjcct(Sec.to an Businessand Professions Code:)The Cs doman'. nd si e�\VO
cense Law JOe not apply a es owner of property who sedp or improves Contras and
who contracts Lacu for veer prjccu with a contnaor(q Iiccnutl pursuant to ve Conuanor's
Licenm Law.
❑ i ore exempt under See. .B&P C for This..an
:r Date
WORKER'S COMPENSATION DECLARATION --
I hereby affirm under penahy of perjury one Of the following declarations:
IC331.1
ban and will mai nand a Certificate of Consent to self-insure for Worker's Comren-
n,u provided for by Section 37M of Be,labor Code.for the perforant,of the
fm which Nis Pcamit is icsucd.
have and will maintain Worker's Compensation Insurance,az required by Section
of the labor Code.fo Ne performance of the work for which this permit is issued.
Wolrk�c's Cyroypeyta..�av,nln mncc carticr a�n''d`1�P^o(`l�'fy numhcr arter'J a�+TIfICA F 8%EMPIION FROM WRKERS'
COMPENSATION INSURANCE
(This union need rot W complcled if Ifc Pdriml is for one hundred dollars(Slip)
mr Icss.)
1 Certify that in the performance Of the work for which this permit Is Issued.I sha11 nut
employ any parson in any tractor so az or become subject to the Workers Compeneadon
Laws of California.Doc
Applicant
NOTICE TO APPLICANT:IL after making this Cenilicale Of Exemption,you should
become subject to the Worker's CoroMplalion provisions of the labor Cndc,you mus
O forthwith Comply with such provisions her this Permit shall W deemed rxvnked.
Z'y CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a COusl uelion lending agency for the performance of
x the work for which this pmanil n issued(SCC.1197,Civ.C.)
Lender's Name
z f<ndcis Address
J Q I certify that 1 ban read this application and sure that the above information is
correct.1 agree to comply with all city and County ordinances and Stam laws relating to
building convection,And hereby authorim representatives of this city to enter upon the
.hove-mentioned depemy for impecddn purposes.
Fa (We)agree r save,indemnify and keep harmless the City of Cupertino against
rip
liabilities.judgments,Costs and ex receives which may in any way acne against mid City
U nedrsegdeneorthegranting ofthis Permit. Issued by: Dale
P LICANT NDERSTANDS AND WILL COMPLY WITH ALL N "POINT
CERE ULATIONS �� I Ill
a Re-roofs
ignawrc o APplicaHVACZARDOUS MATERIALS DISCLOSURE ntiaduour ?` Dale Type of Roof
Will the applicant or future building ncupanl store or handle hazardous material
defined by the Cupertino Municipal Code.Chapter 9.11.and um Health and Safety
soes ridhe zsslz(.)? All roofs shall be inspected prior to any roofing material being installed.
Nd
Will um applicant or future defireg occupant tau equipment Or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
itlef" us air conaminanuaJcfncJM1ythe Bay Area Air Quality Management all new materials for inspection.
isVict?
❑Yes Nu
I h.vc mad the hazardous materials requirements under Chapter 695 or the Califon
P calth ASafcty Cade,Sccdmu 25915.15573 and 755la.l undersand thmif the Wi1di g
I
'Wl curmndy h ve a Wnan,Nat it is my respumihilky W notify the amu and of
meld¢ cnuwhich uNbe pPmWiStuanCCdfaCCNfCAICofOxsU'. Signature of Applicant Date
aushda a age oat All roof coverings to be Class "B" or better