05080213 CITY OF CUPERTINO --*«* as �3 '%-� �° I " � ' '�N';,:
BUILDING DIVISION PERMIT C .... .. TOR IN FORMATIO,.N�,
BU ILDING ADDRESS: STEVEN CHI] PERMITNO.05080213
1( JOHN WY
OWNER'S NAME: PERMIT ISSUE DATE
STEVEN CHU 08/23/2005
NE:
SANITARY NO. CONTROL NO.
ARCHITECTyENGINEER: BUILDING PERMIT INFO
BLDG ELEQ PLUMB MECH
7 �, `o to Eos 0 0
±oma LICENSED CONTRACTOR'S DECLARATION .h4 < ry
4 w= I hemby import Out I am licensed under provisions of Chapter 9(commencing Job Descrlptloni:.tP ;
�Zw with Section 7")of Division 3 of the Bam.and Pomessiars Codm.mm any license is
„ in full to=and elrext. . TEMP POWER POLE h I3 2005
2 License Class Lic.M
a Date Contractor , P
ARCHDECTS DECLARATION
�w u 1 understand my plana shall be used as public records �^ .7 t, �{'�'+
g wi y Licensed Professional U I L 0=7 l� '
On OWNER-BUILDER DECLARATION t��R�YY rl 111"'999 ti:� [t
<f 1 hereby affmt that 1 am exempt from tW Contractor's License I�w for the
-O o following reason.(Section]ID t.5,Business and Pmfessiom Code:Any City or county
`<m which requires a pencil m construct.alter,improve,demolish.or repair any someone
rj 0 0
°-v, prior to its issuance,also mranca the applicant for such permit to file a signed statement
ER< that heislicensed pursuanttothxprovisions Ofthe Comuacw,sLicense Law(chapter 9 Sq.FL Floor Area Valuation
YFG (commencing with Section]0fif of Division 3 of the B topers and Professions Cook)or
y that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 AIJA err UU Occupancy Type
not more Nan five hundred dollars(1500).
I,as owner of the property,or my employees with wages as their mile compensation.
will do the work and the awcmre is not intended or Offered for sale(Sec.1044.Business
and Proressims Code:The Commutes Liame Law does trot apply to an owner of Required Inspections
progeny who Wilchinhoproves sumo,and whoiloes such work himself orthrough his
Own employees,provided Nat such improvements an,not intended or o@red for tile.If.
however.the building or improvement is sold within ane year of completion,the owner-
builder will have the burden of proving that he did ant Wild or improve for purpose of
.1.)
❑1,as Owner of the property,am exclusively contracting with licensed comments;to
construct the project(Sec.7044,Business and Professians Code:)The Contractor's Li
coma Law does not apply to N owMr of property who w4da or impm4es dllrtan,and
who emmrss for such projects with a emoneum(a)licensed pursuant to the Contractors
L4w.
I am exempt undeerr,.SQSB&P C for this rtnon
Owner N,.f— Dvse
�R ER'S COMPENSATION DECLARATION
I hereby affirm under penalty Of perjury ane of the fallowing dechra ki
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
cation,as provided for by Section 3]00 of the Lah it Cade,for the performance of the
wank mor whim this Permit is issued.
❑I Iusve and will maintain Workcr's Compensation Insurance.as required by Section
3]00 of the lever Code,for the performance of the ware forwhich this permit is issued.
My Workers Compensation Insurance carrier and Policy number mo:
Cartier: Policy No.:
CERTIFICATE OF EXENIMON FROM WORKERS'
COMPENSATION INSURANCE
(Tris sections need not m completed if the Permit is for one hundred dollars(SIM)
tar host)
I xerifv that in do,performance of the work for which this Permit is issued.I shall not
employ any pawn in any manncrAo aLmt subject to the Workers'Compensation
Laws of Cabromia Rae
Appiicanl
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of Ne Labor Code,you must
.JZ fmMWhh comply with such provisions or this permit shall W deemed cooked.
zCONSTRUCTION LENDING AGENCY
(-. I hereby Afrm dust Nene is a construction lending agency for tW performance of
6i00 work fur which this permit is issued(Sec.30Y1,Civ.C.)
OU.r Q Lenders Name
]Z Lender's Addncss
V Q 1 certify Nat I have read this application and sure that thm above information is
Hcorrect.1 agree to comply with all city and county oolimis es and sou laws relating to
0(J Wilding construction,and hereby summon,reprnenutiles of this city to enter upon the
}C Amm-mentioned pmNity for irsaction proposes
(We)agree 10 move,indemnify and keep harmless the City of Cupertino against
FN liabilities,judgments.costs and e.,.which may in any way accruc tonst said City �s �7 4�
V zs Permit.
APPL�ANT UNDERSTANDS Aof the gramm,of tND WILL COMPLY WITH ALL NON-POINT Issued by: Date jj--2- -o
SOURCE REGU NS. 4
-- Re-roofs
Signau ApplicanUCon actor - Datil
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant aom or handle havndous mammal
as defined by the Cupenl no Municipal Cods.Chapter 9.11,and the Health and Safety
Code. 0Y35531(4)] 13< All roofs shall be inspected prior to any roofing material being installed.
Ye
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
i,hanrdnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
istrin?
❑Yes
1 have read the baatdnus materials requirements until,Chapter 6.95 of the Califor-
nuHwlN&SafctyCadm,Scott== 5.n533ar 25534.lundctuvdthaifde Wilding
does tat currently have a tenan,than it u my ragxrsibility to notify the occupant Of the
rmquirchana/wy/immustWmet poor wissaarteaof.Certificate ofOicap,ney. Signature of Applicant Dale
Owner authorizcJagcn - Date roof coverings to be Class "B" or better
_ Community Development
10300 Torre Avenue
y Cupertino CA 95014
a Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPERTINO
BuildingDe Fax
JOB ADDRESS: PERMIT #
w a.s 0 �--0 2 (3
OWNER'S NAME: PHONE # 9J 7.2T-
GENERAL CONTRACTOR: p z, FAX # zr - /3,r"a
I am not using any subcontractors: aa—
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
® Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
e Contractor Signature Date
CITY OF CUPERTINO
a TEMP POWERCITY OF
UPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone #:
?-S --ox-
Contractor:
o -Contractor: Phone: License #:
d C�/Jean
Contact: Phone: Cupertino Business License #:
V -FfU
Building
Permit Info:
Elect ok)ft - D
Job Description:
Residential Commercial ❑
Cost of Project:
5W
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
4P t ��