04060119 CITY OF CUPERTINO ,
BUILDING DIVISION PERMIT �C�ONTRA +TQRINFORMATIQN '
BUILDING ADDRESS:
"""'%4060119
ERMIT N0,4 0 6 0119
OWNER'S NAME: PERMITISSUEDATE
1ARCHITECUENGINEER
NE: SANITARY ND. CONTROL NO.
: BUILDING PERMrtINFO
BLDG ELECT PLUMB MECH
uOLICENSEDCONIRACI'OR'SDECLARATION 7obDe �gbtil���®I krcCy arfirm Wr 1 am li¢nscdunerpmviJorisofCluprcr 9(commencingSttdon]IXgDaf Division SofNCBuJnev ProfcuiOmCog mYli"=is
n mrce and area'' TEMP POWER POLE p / �tZncense Chun Lic.N JUN 2 r 2004
ZF Dow Contractor
EE ARCHITECTS DECLARATION
C I understand my plans alu11 k used u public records
BUILDING
U.t; Liccnod Professional
OWNER-BUILDER eactup,f DECLARATION
p3 1 math affirm on I am exempt from rk Contractor's :Any c Law for the
o fallowing oeaabn.(Sail t 700 L5,Business and n,de oli h.or Any city or mcountyma
=� which rcyuiru a pcmhit m rnhuwct,altar.impmn,dcmalish,or repair any atrvcmre
Fi< prior to its issuance,also rcquims the applicant for such permit to rile a signed statement
Nat he is licensed purmam to Bc provisions of lie Contractor's Liauc Law(Chapter9 Sq. Ft. Floor Area Valuation
,,io (commencing with Socton 7")of Division 3o the Businw and Professions Cade)or
y
that has is exempt therefrom and tae huts fen Ne alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit subjects Be applicant to a civil penalty of 3 5VPN/I@ISM%ep0 0 Occupancy Type
not marc Baa Gem hundred dollars(5500).
❑I.u owns of Be property,a my employees with wags as their able compensation,
will do Rework.and We he Cont is tar's License
Law
es hot apply to in BUJnw Required Inspections
and Professions Code:The Cantracton,Liana law does not apply if an owner of q P
Own enywhe s.provided
impmvu Benton,and snit w enot inssuch work himselrarNmugh his
ownemployees,provided Ratsuchimpmnmrntt are not intendedmaOmed the Ofriable. r.
builder..the Wilding or improvement is halt a didb one Sear of improve far
purpose
owner
builder with have the burden of proving that k did tat build or improve fa purymse of
ra has owner of the propeny,am exclusively contracting with licensed contractors to
consumer the project(Sec 1060,Business and Prafessiou Cade:)This Contractors Li.
tabu Law dors not apply in an owner of property who builds or improves thereon.and,
who contracts for such impacts;with a cormosmnrfs)licensed pursuant in the Contracmra
License Law.
lamenempluu.µqtr See / B&PCT this mason
0.. /fes .!i
WORK 'S i MPENSAT]ON DECLARA
I hereby Jrimh under penalty of perjury one of the following declarations: ,
I ban and will manuin a Carom¢of Consent to mlf-iuu a for WarkersCompco-
1037'�'00
ion,u provided for by Section 3100 of the Labor Cade,for the pedona ano of tk
rk for which this permit is issued.
I haw bad will maintain Workers Compensation luurana,u required by Section
ofthe Labor Code,for the pertormance of the work for which this permit is issued.
y Worker's Compcnuuon Insurance carrier and Policy number am:
rtier, Policy No.: '
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
midsacction need rot W completed if tk Petit isformr hundred dollars($100)
or los.)
1 certify that in the performance of tk work for which this permit is issued.I sisal not
employ any person in any manner an as in become subject rim the WOM1en Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:U.after making thla Ccnifleme of Eacmphim,you should
WConre subject to the Worker's CpmpenaallOn pmvisiom of the labor Cade,you must
,J O raMwn,comply with such pmvisiau or this Permit shall k domed ranked.
? ^' CONSTRUCTION LENDING AGENCY
I hereby otfurn Bre Rare is a couwctinn lending agency rank Turfarmnne.of
h(7 the work for which this permit is issued(Sec.3037,Civ.C.)
W A Latices Name
6, Lenders Addmu
V O 1 molly that 1 have mad this application and sum that the above information is
LL E' correct I agme ta comply with JI city and county maintains and sure laws mlaring to
0C) building Construction.and hereby authoria¢phsentalUm of this city m on=upon ftLI] above-racy uoned propcny for inspection Purposes.
0. (We)agree m save.indemnify and keep hamdess t City or Cupertino against
N liahiltuts,judgments,costs andcapenses which may in any way recmc against said City
permit.
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued
fJZ in consequence of Re grenung of Nis by: D e
Data
50 UL S.
ata Re-roofs
rcontnctor
ofAIican
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tab applicant or future Wilding occupant stem or hastdle hvallous material
as dented by tlm Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
ANiPile,Sa❑torex.25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
L7 u
Will the applicant or furore Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
coir ha'rardnus air contaminants u Jcnn by Bc Bey Area Air Quality Management all new materials for inspection.
District?
❑Yes
I have mW Be husNnus mamnalsrequimmenu under Chapter 6.95 of the Califor-
niaHcolB&Saely Code,Sections 25%5,25533 and25536.I understand UncWilding
Jscs not torten a¢nano Nal it is my mapomihilitY w naNy tk w:cuPant ar Nc
require hi a epnara,Lu uf.ccoiricatcor ci,P!Ocy. J Signature of Applicant Date
All roof coverings to be Class"B"or better
caner or summiud agent Dam
CITY OF CUPERTINO
STEMP POWER C)
Y OF 7
UPEkTINO PERMIT APPLICATION FORM
APN # Date:
S / %
Aq 10
Building Addr ss: [bl
Owner's Name: Phone#:
F,5-9-61.22,57
Contractor:
'S -
Contractor: Phone: License #:
Contact Phone:: Cupertino Business License #:
Building Permit Info:
Elect CJ
Job Description:
Residential Commercial ❑
Cost of Project:
Qty. .
A ca le Fee ID Fee Descri tion Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING