03070025 ' CITY OF CUPERTINO °'+ " ��' �'%e • -
BUILDING DIVISION PERMIT CONTRACT ORANFORMATION.:
BUILDING ADDRESS: RYMIK DEVELOPMENT CORP PERMITNOD3070025
3090 HA22T-I�RQQK 17)R.
OWNER'S NAME: 7505 LEEDS AVE PERMIT ISSUE DATE
JN[: (408) 253-1424 SANITARY NO. CONTROL NO.
ARCHITECI'IENGINEER: BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
uO iJ
LICENSEDCONTRACTORS
under
DECLARATION
f U 1 hereby affirm that I..limi ad ender provisions of emptor 9(commencing lob Description
wi,M1 Section TIXM))of Division 3 of the Business and Professions Codc,and my license is
in full force and crfcef
S'q? License Class Lie.A TEMP POWER POLE
Fcs Date Cumfaaaf
ARCHITECTS DECLARATION
wU I understand my plans shall be used as public records
s o G Licensed Pndcssional /;-7/
1 S OWNER-BUILDER DECLARATION
2 a Y 1 hereby affirm that I am exempt from But Contractor's License Law for the O
00 following reason.(Section 7031.5.Business and Professions Code:Any city or county
<m which requires a Permit m gm SIMM.ahr,improve,demolish,Or repair any¢uecture
a y prior to its issuance,also reports the applicant for such permit to file a signed sutcmcm
Edo mat he is licensed pursuant to the provisions of the Contractor sLleenxLaw(Chapter 9 - - Sq. Ft. Floor Area Valuation
y (commencing with Section 7001 of Division 3 of the Business and Professions Cndc)or
i
that he is exempt Ncrefrom and the basis for the alleged exemption.Any violation of 32655031 . 00
Section 7031.5 by any applicant fon permit subjects We applicanuo a civil Penalty of APN Number O
not mom than five hundred dullars(55)o). Occupancy Y Type
0 h as owner of the progeny,or my employees with wages-Meir sole compensation,
will do Ne work,and that swam,is ret intended or offered for sale(Sce.7W.Business
and Professions Code:The Contractee.Lime Law does not apply to an owner or Required Inspections
property who builds or improves thereon.and whodims such work himselfor through his - 304 — ROUGH ELECTRICAL
own employees,provided that such Improvements are not intended or offered for sale.If,
however.Ne Wilding or improvement is sold within one Scar of completion,the owner"
builder will have Ne burden of proving that he did not Wild or improve for puryose of -
sa1cJ.
❑1,As owner of me p,.,n,Int eacWsiwly contracting with licmtsed contractors le.
Mucan ct me project(Sec.7044,Business and Professions Cade:)The CeMWMArs Li.
cerise Law does not apply to an owner of properly who Wilds or improws Merton,and
who contracts for such projects with a cantractor(s)licensed pursuant to the Contractor's
License Law.
empf under Sac. ,B&P far a moan
O nitAa¢?txo
W RKER'S COMPENSATION DEC TION
I hereby affirm under pe-1,y of perjury ore o the fallowing declinations:
I haw and will mainain a Certificate of Consent o self-insure for Worker's Compere
7c-y
on,in provided for by Section 37W of me Laair Code,for the perfmmance of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
W of Ne Labor Coda,for the pctfmmance of me work for which this permit is issued.
Workers ComPen-lion Insurance carrier and Policy number amrtier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu secfimt seed not hecompleted ifthe Tenth is for enc Wndred dollars(SIa1B
or leas.)
1 ccnify that in the performance of the work for which this permit Is issued.I shall no,
employ any person in any manner en as he become stokerto the Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificare of Ewmp,ion,you should
become satteM,o the Worker's Compensation previsions of tbe Labe Code,you most
.J z Rallwill,comply with such provisions or this permit shall be deemed revoked.
zCONSTRUCTION LENDING AGENCY
H Ihemby allbM fear there its construction lending agency lAr the Performance of
!Y
the work fur which feu permit is issued(Site.3097,Ci,C.)
W Lender's Name
=z Lender's Address
V O 1 minify that I have mad mix application and sat¢thI,the above information is
U, F comer I agree to comply with all city and county ordinances and slate laws totaling to
O V building construction,and hemby au,horim representatives of this city to enter upon the
aaovomenudgro ms.fmac costs
for iIspccuon purposes.
H y (We)agree to ave,indemnify and keep harmless the City of Cupsnino against
z liabilitiesjudgments.grantingof thisami1, Out,in any way acerae against-id City
C),� in cnnxyucncc ofthe graining of this perms,.
APP (CANT U GE. AN AND WILL COMPLY WITH ALL N N-POINT Issued by: Date
SO CE RE ATIy{+S. y
�A // �� Re-roofs
Sig�awrc of Date
HAZARDOUS MA IAIS DISCLOSURE Type of Roof
Will Ih applicant or future Wilding occupant same of handle hazardous ma¢rial
As defined by the Cupertino Municipal Code.ChaPtar 9.12.and the Health and Safety
Code,Section 25512(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ODtt
j� { If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which g p
hazardrua air contaminants as defined by,he Bay Area Air Quality Management all new materials for inspection.
uioR
❑Yes x�No
1 have mail the huvardue¢mamrials mquimmenu under Chapwr 6.95 of the Califon
nice Filabb&SafctyCa ,Sccdms 25515,25533 and 25534.1 undcaand thudde Wilding
docs by curmmly have a tcnan Nati is my regomlhili,y m AMR, a pant of me
grant which bent pdr ,iaMmw.fa Ccnlficam er c , Signature of Applicant
Date
O erunuthenac n, Date All roof coverings to be Class "B" or better
CITY OF CUPERTINO
:.� d. TEMP POWER o ),o
SCUPEkTINO PERMIT APPLICATION FORM
APN# � l ' S S Date V U 3
Building Address:
( Ofb / (G e WOK t"c
Ow sNam
PhorLel :Y`� ev O 5- 7
y 2
Co actor: Phone: v{ OY - Z 5-3 LicSryg�. 3 I I
v v�
ntact: Phone: Cu ertino Business License#:
rvlfJ� Q a r `t `i�jj-233-XYZ / 3
Building Permit Info:
Elect ❑
Job Description: & r
Residential Co ercial ❑
Cost of Proje l
Qty. if
ApplicAle Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING