04060054 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONT.RACTnR INFORMATION
BUILDING ADDRESS: PERMIT N0.0 4 0 6 0 0 54
OW NER'S NAME: PERMIT ISSUEDATE
NE: SANITARY NO. CONTR
YU-
OL NO.
ARCHITEC 4ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u j LICENSED CONTRACTOR'S DECLARATION Job Description , J
1 thereby affirm Out 1 am licensed antler pd Popcie of Chapter 9(mmme im is P yC"y3-�
n� with Smtiw]IXX3)af Division Sof the Budneas arW Pro(esdmu Code.and mylicuuc is
infat force mdeRaet. TEMP POWER POLE
p g Z License Class Lic.N
fl
p Dam Cunstarm
ARCHITECTS aDECLARATION
a I undersand my Is.swl W used se public mcialsis c/
isdu r
GLicensed Professional
5 OWNER-BUILDER DECLARATION
I hereby.('Rent Net 1 1. exempt from the Contsecmod License Law for
po which requires
e mason. erten to
7031.5,Bmineu and Pw.denies Ca de:Any City nrcounty
$
Eo which rtqus u n permit re uires;et alar,impose,h comity,fi mash any monclustatement_¢i Pdormits issuance.also mgdisca the applicant for permiuo Ncasigned sutemcnt
< (commencing
encin with
0)ofDivioion3of cBusinessandcnselaw(Chapter9 Sq.Ft. Floor Area Valuation
iim (commencing wide Section 7")of Division)of NC BusinessanO Pmfcuinns Cndc)ar
y $
that he is exempt therefrom and Ne basis for the alleged escmption.Any violation of
Semon 7031.5 by airy applicant fon Permit subjccu the applicant to•cwl penalty of 3 @2II(Mi&16er 0 0 Occupancy Type
mat mum Nan 0w hundred dollars ts5W1.
0 I,u owner Of the proPeny,or my employees with wages as their sole compensation,
will do Ne work and theewcrdte is not intended or offered for sale 7()14.Business Required Inspections
and Pmfmlom Code:The Contrai License Law does not apply m an owner of q P
proper ywho Wildsurimprowdermn,andwhu doessuch work himudforthisuth his
own employees,provided Measuch improwmenu are notinerped oronaW forsale.If,
howmi,Ne building or improwment is mid within one year of completion,On owner-
Wilder will have the Wrden of proving Nat he did not Wild or impmw,for purpose of
sok.).
Las owner of de progeny am exclesiwly contracting with licensed emascwra to
c ns 1:1 the pmjett(Sec.70x4.Business and Profesdom Code:)The Contracmri Li.
ccttu law dos not apply m an owner of property who Wilds or improves Merton,and
Lho contacts for such projects with a contnctor(s)lieensed pursuantto Ne Conhanols
eena Law.
0 1 am caempt undo Sac. .B&P C for Nis reran
own" Data
H T WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perj ne of the following dalaretioes:
I heand will mdradd a CertiOeau of tto self-insum for Workar'a Compen.
cation,u provided for by Section 3700 of the labor Code,for the petro mence of the
work for which Nis permit is issued.
0 I have and will mdno r Wwkcr's Compensation Ittsurvtm,as myuised by Section . .
3]00 of Ne labor Code.for the Performance of Ne work forwhich this permit is issued.
My Worker's Compensation hommi ce carrin and Policy number me:
Camey. Policy NO.:
CERTIFICATE OF MEMP ION FROM WORKERS'
COMPENSATION INSURANCE
Crisis mcd.n.ceal not W completed lithe Iemah isforonc hundred dollars($10()
or IeesJ
1 certify that in Me perfomource of Ne work for which this Permit is issued.I shall not
employ any person in any mamuian as in become subject to daworacca Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL aper making this Ceni0eate of Exemption,you should
become subject in Ne Workers Compensation provisions of the Lehrer Code,you must
2 forthwith comply with such provisions or Nu permit shall W deemed mwked.
Z O CONSTRUCTION LENDING AGENCY
[r Ihereby affirm Nat Nem is.,...truetinn lendingagemy for tW pelf-mum-Of
(S$> Ne work for which Nis permit is issued(Sec.3(1 Civ.C.)
{t1 25 Lenders Name
0. Lattices Address
U C L certify Nn I have read this application and sue Nat Ne above information is
U. comet.1 agree to comply with all city and county ordinances and state laws relating to
building construction,and hereby auNodm mpm anutiws of this city 10 enter drum the
.bow mentioned Property for inspection pdrpeaca
(We)agree m rove,indemnify and keep harmless th
e City Of Cupertino g
ertinain d
t4R1 liabilities,judgments,costs and expenses which may in any way accrue against add City
V z APPLICANcof Me granting of tANhisD
TUNDERSTANDSWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOY13CEREGULATIONS. /
=� - yr �y(Wo(F Re-roofs
Stamm of pplmaonacoo
HAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will On applicant or forum building occupant num or handle haendous material
as defined by tie Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Id-
ds,Sccdonx5531(an ���!!! All roofs shall be inspected prior to any roofing material being installed.
0 Yes rpt Nu
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
it hawrnmet air conuminants as defined by the Bay Area Air Quality Management all new materials for inspection.
suin7
0Yes {T NO
1 have mad the hicardous materials requirements under Chapter 6,95 or Ne Califor-
ReslN&Safety Cede,Section,25505,25537 and 25530 1 unMrstntd thuifthe Wilding
es trot curreyyttI haw a aunt Nat it u my"u"Mo ihility m wiry the Oaupent of the
ch musbomet pdarmiuuawcora CcnifeateamSignature of ApplicantDate
All roof coverings to be Class "B"or better
wner ser aunxd cut One,
CITY OF CUPERTINO o—z� c,
TEMP POWER
Y 01
UPEkTINO PERMIT APPLICATION FORM
APN # /J Date: 6 r, /
C/ D
Building Ad&ess:
Owner's Name: Phone#:
Contractor: Phone:. License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description:
�e�QDra �owen�
Residential Commercial ❑
Cost of Project: r
� 000
Q
A 1'ca le Fee ID Fee Description Fee Group
LV Fl—k BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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