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04060091 CITY OF CUPERTINO � �` r "'' ` "' �" '` BUILDING DIVISION PERMIT rtCONTTRAC.T,OR INP RMAT ON OUILDING ADDRESS: RICHARD SHWE PERMIT N904060091 21840 HERmnSA All OWNER'S NAME: PERMIT ISSUE OATS RICHARD SHWE ONE: SANRARY N0. CONTROL NO, ARCHITECGENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 Lap LICENSED CONTRACTUR'SDECLAKATION Job Description I Mach,arnmh that I am 1iCxnsadde under p visionmme s of Chapter 9(concing wiNSxtion]nox" 'Di " n3o'ou Busircvyp,ppf Code and y pe�I� �tt jjm® inmlYYIn aandeffal. � Y e� V TEMP POWER POLE ■ )J� ibl� j y�Z Llccj lis Le.6 f p Da Cunuacyr nneers (ARCH n DECLARdaspublicm OIC NN JUN 2 l 2004 3a� Lcorria icenced Pnafcasiona `D O - ILDERDECLARATION BUILDING <E I hereby rlfirm that I am exempt from Ne Commchoes License Law for the i o O following mason.(Scotian 703 1.5,Business and Professions Code:Any city or county a�m which reyuims a permit to ennsuum,aMa improve,demniM,Or-pair any"'to' F`e prior to its issuance.also mquims the applicant(orsuch permit m file a signed statement Valuation f�p that he is licensed punuanttothe provisions of the Contmo 's License Law(Chapter 9 Sq.Ft. Floor Area s (commencing with Section7")of Doisioa 3 of the Bosinm and Ponfession$Cudc)tar $ has,he is exempt therefrom and the basis for the allcgcd exemption.My violation of Section 7031.5 by any applicant for a permit subjects the appins rl In a civil penalty of 3.xWtSi�fb193e10 0 Occupancy Type not more than Eve hundred dollars($500). , ❑1.asownex of the property.or my employ.win.,,as their.1.compensation, will do the work and the swctum is not intended or offered for age(sec.7064,Business Required Inspections and Por easiom he Code:TCannanore,License Law d.Met apply in an owner of q P property who builds m improv tbemon,and who dose such work hi mself or through his own employees,provided that such improwmenu are not intended oro@red for Male.If, however.the building or improvement is sold within one year of completion,the—her- builder will brow the burden of proving that he did not Wild or improv for purpose of Mak.). ❑1.as owner of the nore,ty,am exelusivwly contracting with licensed Contractors 10 Conswn the project(Sec.7044,Business and Professions Cade:)TIy Conmccars U. cove Law does not apply tu an owner of progeny who Wilds or impruva thereon,and who contracts for such pmjecu with a contractor($)licenced pursuant ha rte Contractors License Taw. 1 w exempt under Sec. .B&P C for this won Owner Date 0 BMPEHBATYBN-BEEBABAHoh? 1 hereby affiOc under Penalty of perjury one of the following declarations: 1 have and will maintain a Certificate of Consent to self-insure for Workers Compere scion,as provided for by Section 37M of the Labor Code,for the Performance of the work for which this Permit is issued. ❑I more and will maintain Workers Compensation Insurance,v required by Section 3700 of the IoW,Cade,for rte performance of the work for which this Permit IS issued. My Workers Compensation Insumnoe carrier and Policy number are: Carrier: Policy No.: CERTIFICATE OF EKEMMON FROM WORKERS' COMPENSATION INSURANCE (Thu section need not hecompleud if the Permit Is for one hundred dollars($1011) or less.) 1 certify Nat in the perR ante of the work for i,b this permit is issued.I shall not d employ any person in a�anncm.m= $Object m the Workeri Compensation Laws of califomia.Day 1 , Applic9^t NOTIOE TO APPA ANT:If,after making this Certificate of Exemption,you should Wco 2su cot to the W rovisions of the IsMr Code.you muse O Z foMwi romplY with sbch PmvWma or this permits reed revoked. z� CONSTRUCTION LENDING AGENCY (-. 1 Mmby olfirm that them is•Covuucuon lending.,easy for the perfurmanco of p,7 rte work for which this permit is issued(Sce.3(197,Civ.C.) IZ]Q lsnder's Name 0. Lenders Addw U O I Certify that I have read this application and state that the show or..arich is H comoct.1 agree to Comply with all city and county ordinances and cute laws relating to o-mel 0 building eo)agree n.to hindbmnifyad epharpri ivrsof this City upcmnupnn the W aMw-mentioncd property for msPeotion purposes 1 (We)agrees,save,indemnify and keep harmless the City of Cupenst against I, inconw ruedgmcnta,costa and expenseswhich may in any way eccnm against sold City d U z in eonsegnenec of tiro Bsanun6 nu permit. APPL1CAN'r�UltNDER,,��STAaaN ANO WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE RE LATI /1 t�Q t_ Re-roofs Sig narere.fA auxV2e cm caw HAZARDOUS MATERIALS DISCLOSURE . Type Of ROOF LWill applicant or future Wilding Occupant store or handle ha]ardov mammal imed by the CupeNno Municipal Cade.Chapter 9.13,and the Health and Safety 1niMHC,hh&SafcIyCCd1c. ode,Section 2553200? All roofs shall be inspected prior to any roofing material being installed. ❑Yea If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future Winding Occupant tae equipment or devices which mit hazardous air Contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. istrict? E3 yes 1 Mvc read thc havNrms materials mquimmenu under Chapwr6.95 of rte Califon cuuv35505,25533am135534.1umersundthatifthc Wilding oos not currently haw a ant.Nat it¢my mope ihdity m no the arupont of the require. Inch E or fourtulesusnceafa T¢amafDecoC�y'CL SlgnatureofApplicant Date neo cat 66 Date All roof coverings to be Class "B"or better CITY OF CUPERTINO U 4 o v TEMP POWER CUPEI�TINO PERMIT APPLICATION FORM ',,PN # S 7 ( 6 a S Date: l d ^ S Building Address: Owner's Name: (� \C Ione#: � Contractor: [� Phone- 'Z6 1 — It License 12� �© �ol� �orn ti °o Contact: f C✓lG�� c Phone: Z� l t Cupertino Business License#: Building Peennit Info: Elect Job Description: Residential ❑ Commercial ❑ Cost of Project: 0 O • Qty. if Applicable Fee ID Fee Description Fee Group BTEMP Temporary Power ELECTRICAL EPERMITFEE Elect. Permit Issuance ELECTRICAL BUSLIC Business License BUILDING •