04020174 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONaTRACTOlq INFORMAT-ION`e'
BUILDING ADDRESS: PERMIT NO04020174 4020174
OWNER'S NAME: PERMIT ISSUE DATE
CU LE & L
NE: SANMARYNO. CONTROLNO.
ARCHITECT/ GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
u00 LICENSED CONTRACTOR'SDECLARATION Job Description
C 1 hereby affirm that 1 am licensed under provisions of CNpter 9(commcming
b with Section 7WB)of Division Sof NC Business and Professions Code.and my he...is
or infull mrroand effect. TEMP POWER POLE
j z Liaise Class ti
1C Contractor F Da
'
^� ARCHITECTSS DECLARATION ARATION
0v a< I understand my plans shell he used as public rmwm
MAR 0 5 2004
''p Licensed Pmfcssionel
OWNER-BUILDER DECLARATION
I hcrchy air.thin I ore escmpt from the Comramoh License Law for the 1
Ir/`
00 following moon.(section 7031.5.Business and Profusions Code:Any city or county ®v1`®�
K$ which myuim,•Permit w t,cm,comL sliimprove,demolish.or repair any suuetum G.
' j,n prior in its issuance.also requires the applicant for such Permit o file a signed suwment
< Out he is licensed p...ortothe provisions oftheComment's License law(Chapter 9 Sq. Ft. Floor Area Valuation
ars (commencing with Section 7000)of Division 3 of the Business and Profeuinu Code).1
y Nat he is exmpl Ocmfrmn and the basis far the alleged cmmption.Any violation of
Section 7031.5 by airy applicant far a permit subjects the applicant 0 a civil Penalty of 3701934hi33BarO 0 Occupancy Type
not more than fns hundred dollen(2500).
❑L u mvnerk.the propmty,m my cm undedwith wages as sale(Sm.tom.Burso on,
will dadxwork ande:Tim tommelots License offered rot dr apply 7o aa.Boner s= Required Inspections
pro,and Profecdom Code:The Conhinner. .d toe Lew ch nut apply to an owner or q P
Own enywho b.mvided dints thjorpra ovenwh.daenot In wiled oro lied Nroughhi=
ownemployees,provided Nn suchim I,sold nuarcnotinundedoroRcredforeamu-
Wilds,
however.iH building or improvementissoldwithin arc yeti of mprove I.
Ou owner
builder wiB have Ox burden of proving WI he did not buildm Improve fw purpose of
Oak.). .
a mvncr of the pmpcny,am esc nsively co ndramg with limned ren duchers in
I the project(See.7044,Business and Profusions Code:)The Con occur s Li.
e Law docs not apply to an owner of progeny who builds or improves thxon.and,
who contracts for such projects with a chro acwra)licensed pursuant w the Contnewr's
License law.
❑lam acmpt ndw See. .BRPCf thl n
Ovr Dau
V KERS C MPENSATION ON
(hereby under petWty of perjury one of the fit 'ng dmlantians:
I hamandwil ainuinaCcnirimxof Conxntwxlf-imumfmWw esComNc -
anamn,as Provided for by Section 3700 of the Labor Code,for the perform one of the
work for which this permit is issued.
❑I have and will maintain Wool Compensation Iruuraws,as mquimd by Section
37W of the labor Code,for the performance of Ne work forwhich this permit is issued.
My Workces Compensation Insumtrcs tender and Policy number am:
Curie, Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
Thuseetlan modern M complexi ifdx po mit is fmone hundred dollars(SITU)
or less.)
I certify that in the performance of the work for which this Permit is issued.l shall not
employ any pose.in any manncrx as to become subject o the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this CeniRcate of Exemption,you should
become subject in the Worker's Compeasation provisions of the Lahor Code,You must
.,Z foMWOh comply with such provisions or this Permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(.n I hereby affirm Nat them is a construction landing agency for the performanco of
IY> the work,for which this permit is issued(Ses.3037,Civ.C.)
!L1 Q Lenders Name
C Lender's Address
V C 1 cent that 1 have rid this application and coup and dux thn the some l sus odatiun is
11.U builds.1 egret m comply with all city and county ordinances and atsx laws relating e
U Wilding mnstmd property
rorimpmhorixmpreunutisss of this mcnur upon the
r W ahovc(W tion agree
to S try tar sormy an Purposes.
F 4L (We)agrm w sem,iMcmnify and trop harmless the City of Cupertino against
fn liabilities,judgmental,costs and expenses which may in any way&ce=against said City L&
U z in consequence of the gnnnng of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AlL NON- owr Issued by: Date
SOURCER ULATIONS.
Re-roofs
S' More f AD icanJCanua<mr en
HA]ARDOUS MATERIALS DISCLO Type of ROOF
Will
an
or future building Occupant store or handle ha Mous matenal
as defined by the Cupertino Municipal Code,Chapmr 9.12.and da,Hcahh and Safety
A119oust.Section u532(a)9 LIZ
roofs shall be inspected prior to any roofing material being installed.
p Yen
Will the applicant or future building mcupanl Use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hayardoos air conumimmo u do ned by thc Bay Arta Air Quality Management all new materials for inspection.
District?
(]Yes Nu
1 havemadtheh.Secu=25505. requimmenuunderCMPur6 aLifOu CeldinS
nu Hcalthlk SefctyCak.Sections atili25533vom:m4.1wnodfnd =Ox lofW g
Jues Dat c Oy ham•xnanl Nat it u my resp,nsiMlity w notify Ox amupmt of Ne
mgmremcn Hien most met priorwissuancc or a Ccmficau of Occur . ignature of Applicant Date
All roof coverings to be Class"B" or better
oet oat <dagent D.
CITY OF CUPERTINO r�
TEMP POWER
Y OF
UPEkTINO PERMIT APPLICATION FORM
in APN# s 1'W 3 Date:
Building Address:
Owner's Name: Phone#:
G L- 12 L-.- N CC. -
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
El
Jog Description:
Residential Commercial ❑
i
Cost of Project: �-
Qty.?f"
AppWaVle Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
Jos A 3 0 l S N y✓ FWpFgTIPERMrr #
OWNER'S NAME�>4 L N PHONE .,
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical a.53
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 q
Owner/Contractor Signature Uate