04100175 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRAC`I'OR�INFOTtMATIQN :
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OUILDINGADDRESS: PRICE BROTHERS CONSTRUCTIONPERMl7'N 04100175
OWNER'S NAME: PERMIT ISSUE DATE
PRICE BROTHERS CONSTIRTICTIC)
ONE: SANITARY C OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT - PLUMB MECH
0 0 0 0
uo0 LICENSED CONTRACFOR'S DECLARATION Job Description ' -
�i I he by firm that I em licenned under provisions of Chapter 9(commencing - -
wimSrcuon )of Divii n]of NC Boommoande�fession Code.mdmy licenmia
infallr aercm ✓ `I'�9 7S4Q TEMP POWER POLE
5�? Clearest Class Lie./
al-
f❑ Dete Contractor -
y ARCHITECTS DECLARATION - -
Y 1milerann my planaahJl W used as puhllrs®a6 -
OyU
GLicensed Pmfcnionel -
3 OWNER-BUILDER DECLARATION
1 hemhy affirm mat turn exempt from ft Canuacmh License law for IN, .
i p O following reason.(Stenon 7(51.5.Business and Nvfe tions Cole:Any city nr county,
which requite•permit m comuuct.atoll,improve,demolish,or repair my structure
er-'n priortoiu issuana.auu require JIT applicant for such permitto fileatignW au¢mem Valuation
90
Ez'<
that he is licenced pursuant to me provision of the Conuazmrs Ulew Law(Chapter9 Sq.Ft. Floor Area \"A�
�$ (commencing with Section 7"1 of Division]ofthe Business and Professions Code).,
_ lost he a compel therefrom and the bnu ran dm alleged exemption.Any violation of ��}}vT,��
Section 7011.5 by any applicant fon.permit subjcota the ahplianl m m civil penalty of 3 i.w�ilhi.....tM 0 Occupancy Type
not mart man five hundred dollen($50)). OMd� '6Yf��'
I,as owner of the puesloc,or my emphyw calm wage a the'v sole comperumsion,
will ea mawort.ande:Thnumutets Lieut orortemnce;.1 apply?o an Bnerof Required Inspections
and Profession Cute:The ConhecmYs Liarue Law doe Int apply to an owner is q p
Own emplo who
ceuiProvi id thatsschimpr end who doesauchwdedoro emdthrough his
own employers,provided that improvements tic not mo off oroReme Omuta.If.
however,the Wilding or umprowmcnn is sold within one Scar of mprov for me owner-
bulleer will have the burden of proving Net he did not Wild or improve far purpose of '
sale.).
El I,as owner of the property,am excisswely emarecting with licensed eomosetom h
construct the project(Sec.70ae,Bosunes and Rofeasion Cade:)The Contractors Lt. _
cense Law docs not apply to an owner of property who builds or improves thereon,and
who commuter for such pmjecu with a eonuaact(i)licensed puremolto docontractorm
Licenx Law.
1 stn exempt under Sec. .B&P C for this mason
OwnerDate
WORKER'S COMPENSATION DECLARATION
1 hereby&Rrm under penalty of perjury on of the fallowing decimations:
l have a ad will maintain.Certificate of Content w sel6unure fou Wmksr'm Compcm
sation.u provided for by Session 3700 of the Labor Code,fm the Performance of the
work for which this permit is issued.
1 have and will mainuin Workers Compenation Inunnce,az required by Section
]700 of the labor Code,for IW perfarmmee of the work for which this permit is issued.
My Wormers coompsea oda las rance,carrier and Policy number ere: tem
Colter, �y1 Ga-kX_ Policy No.: 1-
CERTIFICATEOF EXEMPTION FROM WOR KERS'
COMPENSATION$MANCE
(Thu section need not W completed ifthepersah is fmone hundred dolleraill )
has.)
I unify Nat in the performmee of the work for which this pcmtit is issued.I shall nut
employ any person in any manner an as to become subject o the Workers Complication
Laws of California,Data _ -
Applicant
NOnCE TO APPLICANT:If,aMr making the Cenifici a of Eacmption.you should
become subject to the Worker's Campcnauon provision of the labor Code,you most
.JO forthwith comply with such provisions or this permit shallW deemed revoked.
?� CONSFtUCTION LENDING AGENCY
Fr (hereby affirm mat Bert is a construction lending agency for the Performance of
IY 7 the work for which thu permit is issued(Sec.3097.Civ.CJ
W In Isntless Name
6. finders Addroas
V p 1¢reify that I have mad mus application and sloe mut the above unfmmesiun u
U.P commet.I agree to comply with all city and county oodinmmes and au¢laws relating to
of
<]V building co)agree in
Inde lifyand epraenutun,Beis city toerenter
ino agape
W above-mentioned property for inspection purposes.
1 (We)mgme to ave,and expen ane kith harmless ¢City of Cupertino against
rh liabilitie.jutlgmenu.cosu and expenses which may in any way acrnc gamitmdCity
V z in conu,mencc of the Bnnhng of this permiL Date
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURC GULATI NS.
I ICY�!n X6'21 d 1 Re-roofs
grgnmuic ol'Appliam/c n ter °itoa of Roof
HAZ DOUSMATERIALSDISCLOSURE Tye
Will the applicant or future building occupant atom or handle huardous mamdal
U dcfincd by the Cupertino Municipal Code,Chapter 9.11,end the Health and Safety
Coda.Soman 2591(+0? - All roofs shall be inspected prior to any roofing material being installed.
❑Yesrl u If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant ue equipment or devices which
emit haurdow air conurnmaner all Jefincd by the Bay Area Air Quality Management all new materials for inspection.
Disuim?
❑Yes d No
1 have mad dm hesardousmawriau mWimmmos under Chapter 6.95 of the Califor.
no Heald,k SafetyCode,Section 25515,25533 and MM.l undersmW bleifloc Wilding
does not currently have a emm that it u my responsibility to runty the occupant Of the
regw nerwhichmuat mclpdkin.sa Necpfa nO am Occupancy. Signature of Applicant Date
jj�Ql0-Z'7,-(N All roof coverings to be Class "B"or better
wum,amhorivs gent Date
CITY OF CUPERTINO
Sk�
TEMP POWER
CUPERTINO PERMIT APPLICATION FORM
APN# 362- Date:
/6 -7—o
Building Address:
Own 's Name, Phone #:
IC9
Contractor: Phone: License #:
�t h� ka 813-9990 zlio
Contact: Phone: Cupertino Business Licehse#:
s�i3-99 0
Building Permit Info:
Elect ❑
Job Description:
Residential [ Gommercial ❑
Cost of Project: C>C'
d
•
Qt ."i
lic 1 Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING