04090249 CITY OF CUPERTINO ��^^ '�' �' �` I
BUILDING DIVISION PERMIT :COI�TfTRACTOR�ORMATION R
'°C ,
BUILDING ADDRESS: CUPERTINO CONSTRUCTION INC P11"Nf04090249
21089 GREENTEAE DR
OWNER'S NAME: PERMIT ISSUE DATE
Aghk DANNY LEE
ONE:
SANITARY NO. CONTROL NO,
408 253-9000
ARCHITECUF1sGINEER: BUILDING PERMIT INFO
DG E r-WI MECH
ti00 LICENSED CONTRACTOR'S DECLARATION Job Descri on Lallr
F I Muby affirm that 1 am littived under pmvoimix of Chapter 9(commencing P
with Section 70M0)af Ofvirion 3thftbe Businw and Pince mCode,urd my license is
infullfoneondeffeet' TEMP POWER SEP -?1 2004
SH Z License Class Lic.N
i_i p Dam ARCHRbe use DECtcLARA N BUILDING
C I uMeuund my plans shall W used ss public ATION
JyU
;Q� Licensed Professional
OWNER-exempt boo Ce CmureON
I bertby.(Sc that 1 1. exempt from the Cardona Co license law for the
00 fallowing reason.(Section 703 1.5.Business and Re.de tins Code:Any City of county
Q which requires a permit m cnnslmcL she,nt forse,h permits fie a sig any swcmtc
priono its issuance.atm acquits the applicant dm C.h permit m filC.signed Chapuustatement Valuation
F Z 0 Nat he is licensed pursuant m the pmviuons 3 the Conu ictus Liccnsc law(Chapter 9 Sq.F[. Floor Area
rt5§ (emomea"ingwit"=mim-7")of Di.uionr thisthe Buunnasandon.A.yovi CMe)of
that io u exempt theufmm and the baso for bj alleged eumant to Any violation of
no,
Section tryreddallars( ermhsubjecss theepplicanuo,civil penalty of 32MtA8i�Iildbe100 Occupancy Type
not more Nan five hundred dollen(g50M).
I,as owner of the pmpeny.M my employ".with wage as their sole compensation,
Will do the work.a ad the swctum is not intended in offered for sale(Say.70th,9uuasa Required Inspections
Md Pmfco mts Cade:The Conmmor's License Law does not apply he M owner of q P
Property who builds orica,mvis Ihemori who docssuch work himself or through his
own employers,provided dmtsach fmpmvements art not intended.1,61 W fm sale.If.
however.the building or improvement is sold within one your of eempleuon.the owrer-
builder wi0 have the burden of proving that he did not build or improve for purpose of
sale3.
1,as mom of de property.am exclusively contracting with licensed Canuacmn to
construct the pmjecl(Sec.7044,Business and Rofetions Code:)The Generou s's Li.
cense law does not apply in an owner of pmpeny who Wi1N or improves thereon,Md.
who contracts for such pmjeeu with a conuactor(s)liamed puramou m use Con='Oe3
License law.
❑1 am exempt under Sec. .B k P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of tha following declarnions:
1 have and will maintain a Certifies of Consent or self-insure ftc WerkeYsCompcn-
as inn,u provided for by Section 37M0 of the,labor Code.for the lifermana of the
work for which this permit is issued.
1 have sed will maintain Worker's Compensation Ineumm e,as acquired by Section
37 of doLx,Cook.for do performance of tbe work forwhich this permit is issued.
My Worker's Compen lion raga c 'u and Polity number
Cartier. .0 N Policy No.: w2 ��
CERTIFP OF EXEMPr10N FROM WORK S'
OMPENSATION INSURANCE
Ohoscono need not W completed If the permit IsforonchunUmddollars(Slip)
in,less.)
1 unify that in the perfo rroax,of the work for which this Permit u issued.I shall not
employ any person in any mmnefu as be become subject in the Workers'CompcnsaUon
Laws of California.Dare
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Componsauthn provisions of the Leber Cade,you must
2 forthwith comply with such provisions or this permit shill W deemed revoked.
z
tZl CONSTRUCTION LENDING AGENCY
H.�.. I botchy affirm Nat Nem is a construction lending agency for the Performance of
lY> the work for which Nu permit u issued(Sec.3097,Civ.C.)
W0 l<nN/s Name
O. lantlets Address
V C) I certify thn I have read this application and au¢that the above information is
U, correct.1 agree 10 Comply with all city and county ordinances and state laws testing to
V Wilding Construction.Md hereby auNariu scpmsenuuves of this city mcnlu upon the
P.W ethicdo,juonW propertycosts
for
and Cx,amx puHw.va
F a (we)agree In save,indemnify and keep harmless tie City of Cupertino against
N liebllides,Judgmcnu,costs antl capcnsca which may in any way accmc against mid City
L)z in consequence of the granting of this permit. Date
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATI NS.
Q
/Sl p � -)3-9
Re-roofs
Signature of ApPlicaroConoxactor Dorea of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building Occupant store or handle hvardom material
eco defined by the Cupertino Municipal Code.Chapur 9.12.and Ne Hold,and Safety
Code,Secuon 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes A.
Will the applicant or future buildOccupant tau equipment or Ucvias which If a roof is installed without firs[obtaining an inspection,I agree to remove
ing
mit harardnm air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes AN. �-s
IhavercW thehaxardtons MM5, rt33 and5534.1rChaptcrd.95 CfIW Califon / Z S_
nice mtcumn(lyCCN.Sccuons atiLi25533an MibiiitYWnrsuedthmifthc Wilding
Docs trot currently hove a mnank Net it is my responsibility m noul'y Ne aeupanr of the
rey ' mess which mu ma orw issuance of a CCMflCae of Occupancy. Signature Of Ap Kant Date
�e� D' All roof coverings to be Class"B" or better
Owner'r whorixed agent Da
CITY OF CUPERTINO U o Z�
TEMPPOWERSAIVI-
4)CUPEkTINO PERMIT APPLICATION FORM
APN
Building Address: /a
Owner's Name: 7� ¢� 2 Phe
1/GC�I W 2
Contractor: — , Qhone n License #:
Contact: Phone: Cu ertr o Busin,ss License#:
PbACA r,6, za -Svv
Building Permit Info:
Elect
Job Description:
Residential Comp ercial ❑
Cost of Project:
• 1
if
A 1 a e Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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