05090022 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION'
BUILDINGADDRESS: K & M DEVELOPMENT INC PERMIT NO 05090022
OWNER'S NAME: PERMITLSSUEDATE
Ahk RAYMOND LIU 1060 WEST H 09/06/2005
HIS: SANITARY NO. CONTROL NO.
(408) 253-9787
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 UM
°00 LICENSED CONTRACTOR'S DECLARATION JobDescri [ion
UI hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing p
with Section 70(10)of Division 3 of the Business and Profession Calc,and my license is
u. thmnrome dell«t �/1� TEMP POWER POLE � jr
2 License 1ys` Lic.N L
p Dam Clss` Commcmr - .a.J� [i J 4:.e�Zt,s,:.: also
ry ARCHITECTS DECLARA ON
1 understand my plans shall W used as public retold.
=;G Licensed Professional `"P Z$ 2005
OWNER-BUILDER DECLARATION
<Z I hereby affirm'bar 1 am exempt from the Contractors License law for the
00 following mason.(Section](171.5,Business and Profession Code:Any city at county a1 a ^'LL4 i ,,A,- �y�
L g which Mqulus a perm mit construct,alter.improve,demolish,m PIZ repair any structure ,1 h)1 A I �N vti� 2 0 0
rZ< prior to its issuance.also requires IW applicant for such Perming his a signed sutement 53f/ , ®k:��, dd
(bat W is licensed pursuant o the provisions of ft Contractors License Law(Chapter 9 Sq.Ft. Floor Area WflatiOn
SFO (commencing with Section'l000)of Division 3 of the B ueiness and Professions Code)or
W�3 that he is exempt therefrom and the basis for Ne alleged exemption.Any viOladon of
Section 7031.5 by any applicant for a permit subjects the applicant to acivil Penalty of e{ Occupancy Type
not ream than five hundred dollars(5500).
L u owner of.d properly,m is t:nl arms with wages r their sole W,Busia is
will Professions
antler he Cont is noti Livens Law
wneros
and Professions Codc:The Contractor's License Law dors not apply lf an owner of Required Inspections
property who builds or improve thereon,and who does such work himself or through his
retroemployes,provided provemimprovementsarcnot ear of cmoffcmtl far aide If.
builders the building or improvement is sold within one year of completion.Ne
builder will have the burden of proving Nn he did not Wild or improve far purposepose of of
nicJ.
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7814,Business and Prokension Cade)The Contractors Li
cense law docs not apply in an Owner of property who Wilds or improsea dtercon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec. B k P C for this mason
Owns, > Dam A
70171K OMP m1rlm NDECLARATIOIV
I hereby affirm oder p ty of pe j one of the following declaration:
I haw and will mainmina of Consent to self-intim for Workch Compere
M
ion,n provided for by Section J]M of the labor Cade.for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
of the labor Code,for Ne performance ofthe work for which this permit is issued.
Workers Compemmion I...ca Tier and Policy nmber art:
rrier. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sectionneed not W completed iftle permit is foronc hundred dollars(SIM)
or Mss)
I certify that in the performance of the work for which Nis permit is ismcd,1 shall not
employ any person in any manne�ays11(baffge subjecuo the Workers'Comp Tomo n
Laws of California.Dam �/// ��
Applicant �'7.Tl�s Yom+ /)
NOTICE TO APPLICANT:If.after making Nis CeryR a e of Exemption.you should
We....Object to the Woher's Compcnation pros ons of the labor Code.you mus
z forthwith comply with such provisions or this Permit shall W doomed revoked.
zCONSTRUCTION LENDING AGENCY
.F'� IWrebY aMo.that there is a mntrucdnn lendingageney for the Performance of
Cthe work fur which this Permit is issued(Sec.3097,civ.C.)
W 0tondo's Name
0. Lender's Address
a z
U 0 1 certify that I hers read this application and some Nat the aWw information Is
it,P connect lag=to comply with all city and county oNinantts and sum paws relating to
0U building convection,and hereby authomrz mpreentmiws of this city to enter upon the
4 above-mentiuned property for inPecdon purposes.
(We)again to save,indemnify and keep harmless the City of Cupertino against
Hk/1 liabilities,judgments,cos.and expenses which may in any way accrue against said City
U in conequena of the granting of this permit
r^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S=NS.
NS.
a S, ,
Re-roofs
H n.OUS MA IAIS DISCLOSU Dam Type of Roof
Will do applica rfuture huil ' goccupanutom or handle hazardous mamdal
as defined by the Cupe inn Muni Codc.Chapter 9.12,and the Health and Safety
cam,Scenes 25532(a)
❑Yes Ognu
. y` All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Wilding Occupant use equipment or device.whim If a roof is installed without firs[obtaining an inspection,I agree to remove
Pit Wardnus air ccomminann,as defined by the Bay Area Air Quality Management all new materials for inspection.
DisricR
❑Yes
I have mad Ne hon oats mamrialsmqultemcn.under Chapterri.95 alike Califor
aria Heid"Smfini,Code,Section255)5,25533 it 25534.1 undersand thatifthe Wilding
docs not currently have a that air an,responsibility in madly the mcupant Of the
requrmmu erl
cenawhchWmortt' gan..I.Certificate Of0C cr. Signature of Applicant Date
Owoen or awhod ed.gent Dam All roof coverings to be Class"B"or better
Community Development
r J : 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT #
of/�s5 C/���✓��� ✓G O S0 loo 2'L
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR. FAX #
I am not using any subcontractor . -
9 6 os
" atuye Date
Please check applicable subcontractors and com 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
Owner/Contractor Signature Date
CITY OF CUPERTINO
`CCS-- TEMP POWER 0� v� d 2 2-,
It
PERMIT APPLICATION FORM
APN # - � lz� Dat � r,S
Building Address:
/SSS G�/7r✓�1�� 19vc—
Owner's Name: Phone #:
Contractor: Phone: License #:
z_f-. •,;66 390. Si z �¢i �'�/7Z
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Elect
Job Description:
Z✓S /,aLL ,Gr'J�O2/�.r . �OaIC�/v.
Residential IN Commercial
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ✓ ELECTRICAL
/ EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
� 6-9 , � 7