04100053 CITY OF CUPERTINO
BUILDING DIVISION PERMIT GONTRACTO;R INFO,,RMATIOIV�i
atnLDwcnoDRFss: NATIONAL CONSTRUCTION RENT PrSITNo04100053
OWNER'S NAME: PERMIT ISSUE DAM
NE:
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMU INFO
BLDG ELECT PLUMB MEC"
0 0 0 0
_op LICENSED CONTRACTOR'S DECLARATION ggg�����og
_ I ion 7 affirm Thd 1 am licensed under provisions of chapter 9(commencing Job D I AL E
with Section by al of Division m licensed
Bd n der pr Professions Code.arta my license is
jM=n in full from, adoffeeL TEMP POWER
License Class Lic.g
Z—p Data Contractor
W ARCNrIECTS DECLARATION OCT zc 1004
z< d
1 u .rsund my plans shall he used S public records
JyV
;ox Licensed Professional ATIOBUIL®I N G
q 5 OWNER-BUILDER DECLARATION
+y� 1 kehy affirm Thal I am exempt from theATIOContractor's License Law for the
i00 following memo,(Section 703 1.5.Business and professions Cc&:Any city or county
u�2 which requires a Permit to enmuuct.eller,impar.,.demolish,nr repair any structure
prior m as issuarce,alw equine the cep aieanl for such Permit to file a signed sutement
dust he is licensed pursuant to the provisions of the Contractor's Liavc LAW(ChapLet 9 Sq. Ft. Floor Area Valuation
QFC (commencing with Section IWO)of Division 3 of the Business and Professions Code)Or
that kis erompt tkefrom and the basis far the alleged exemption.Any v101adTo of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 238H1ftM bSr0 0 Occupancy Type
not MOM Nan five hundred dollar(SST
❑I.S ownes oflW gopmty,oc mY employees wish wages S Uu'vmle wmpenStisn.
willdodework.enddans awnureisnotintendedoroffcrtAforsalc(See.7044,Business Required Inspections
and Professions Code:Thc Contractor's Licen,License Law docs not apply to an Owof q P
property who Wildsorimproves lhoson,an lwhodocato ch work hireself ortittnugh his
own employees,provided that such improvements are not intended oroRered future.If,
however,Ne Wilding or improvement is Sold within oro year of ourPleuon,Ne owrur-
builder will have abs,buNen of proving Nn he did not build or Improve for purpose of
S J.
h as Owner of Ne prop.ny,am eselusively contracting with licensed conmeoot to
an met the project(Sec.7014,Bnsineas and Professions Code:)Tk Comramor's Li-
GenuTswd not apply to an owner of property who Wilds or improves tkmon and
ra
who contto such pmieeu wish a eontramr(s)licensed pursuant to the Contractors
❑lamnsem
B
der See
The m G /r7Y
WORK COM EA ION
1 thereby affirm under penally of perjury one of the folio 9 race aratio s:
1 have and will maintain aCen teew of Cm;em to self-insure,for WorkersCompen-
sad.m.as provided for by Section 37M of the labor COLIC.for Its performance of the
work for which this permit is Ssued.
❑1 have will maintain Worked Compewtion Insurance,ss sequined by Section
3700of a bar Cede forth, mmanw of the work for which Nis permit is issued.
My W kers Cnmpensa' n los a carrier and Policy number art:
Ca Policy No.:
CE CA F EKEMPITON FROM WORKERS'
CO PENSATIONINSORANCE
COOS seeunn hand not he completed ifthe Permit is forone hundred dollars(SIM)
or less)
1 certify tot in the performance of the work for which This Permit S ismed,f shall nut
..ploy any pcnon man.manaurm.0 kcomc subjal to tk WmkrsCompeassuon
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,Site,making this Cenifscs.of EacenNun,you ahead
become subject th the Worku's Compensadoo provisions of the Labor Code,you must
Z forthwith comply with such provisions or his Permit shall k deemed rooked.
ZO CONSTRUCTION LENDING AGENCY
Enth. 1 hereby&Man that them is a consuuctire Lending agency for raw perfurmanco of
R:> She wart fm which this permit is issued(Sec.3097,Civ.C.)
W Lenders Name
M Lender's rarydresst
V I Mccmify Nu I haw mad Nis application and suss that the eWw information is
IL F correct.I agree th comply with all city and county on inam,s and save,laws elating to
0V Wilding conswcuon,and heeby sushonre representatives of this city to enter upen The
} W ahOv6menllOOed pmpenY for InapCedOn ParpOaes.
gy (We,)agree to Sae,indemnify and keep humless she City of COPCrInp against
H N
Liabilities.judgments.cos;and as,.which may in any way acetic against said City
O z in conuq of to granting of this permit.
^ APPLII:ANT NDERSTANOS AND LL COMPLY WITH ALL ON- INT Issued by: Date
SOURCER LATIONS. G0
o Re-roofs
Signet Applicant/C t mor V U
HA' DOLS h \TERIALS DISCLOSURE Type of Roof
Will dm applic rfuure building oaupant store or handle hwurdous material
M
as ed by the Cupertino Municipal Code,Chapter 9.12.and Thc Health and Safety
Code.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
0ya Nu
uwrc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Will she applicant or
11 h ,ardour air em uminan; defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes Nu
Ih ad theh.ldOmsmawdalsmquimnunuundcr Chapwr6.95afdte Califon
ria Heal &s clyCoh,SccuoM25505,25533md2553d.Iundcrsundthuifth. Tiding
den n curt ray have a sewn the it is espo ihility m nmify the u of the
¢qui mea hich tk t ra enirtcateorGca cy. Signature of Applicant Date
o nerar tnnriy,aage D, All roof coverings to be Class"B"or better
Community Development
Zu-��
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY 0,
Fax(408) 777-3333
�UPERTINO
Building Department
JOB 041-w C�lGn�o� Sl, PERMIT #o �//
OWNER'S NAME: 0-- PHONE #
GENERAL CONTRACTOR: y, 7 ,wL FAX #
I am not using any subcontractors: �®
Si tore Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
r/Co trac rSignature Date
CITY OF CUPERTINOC S�
(G. TEMP POWER
OCUPEkTINO PERMIT.APPLICATION FORM
APN # -3 �� 1 I Date`
Build'n Address:
Gfl c Glut C-op 61Z C42i� J
a
Owner's Name: Phone #:
Contractors. Phone: _,V-3S,- License#:
Contact: // \ Phone: Cupertino Business License #:
BuildingPermitInfo:
Elect CJ
Job Description:
Residential Commer ial ❑
Cost of Project:
Qty. i
Appli#le Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE 'Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING