06020123 CITY OF CUPERTINO
BUILDING DIVISION PERMIT kONTItAGR'IFk'URM;1.'CIAN
Buaowc ADDaPss: ROBERT PUTNAM - PEaMrr N0.06020123
10251 J Y AVE
OWNER'S NAME: PERb ISSUE DATE
ROBERT PUTNAM 10251 JUSY AVE 02/21/2006
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION JbAP}epSCrl
rd aJ 1 hereby&Man that 1 Am licensed under provisioru O
of Chapter 9(commencing O ��t
with Section 7")of Divlaton 3 of the Bud.and Nor esd.nv Code.and my license b
in full to=and erect. el�i' a9/ t.1 TEMP POWER POLE ion LED
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ARCHRECTSECLSHA records L__
F-; Za 2006
Q� I undcnd my plans he used u public
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Licensed Posfcssianal "I s:
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OWNER-BUILDER
exempt
DECLARATION BU
�b�sg���A �]�
4 O O I hereby.(Rein that 1 1. exempt from the Convector.License Law for the i1W�ylF1T If(1)7 1lal J/R11 lljtlli7l U�VVp�
is O O following reamn.(Section 71171.3,Business and Professions Code:Any city or county yS`15
$Pi which inquires•permit to conanuc4 slier.improve,demodbh,or minor any structure
prior to its issuance,also requires the applicant for such permit to rile a signed sutement
pp <
that heI.licensed pursuammthe Provisions ofthe CanuatorsuccemaolAw(chapter 9 Sq.Ft. Floor Area Valuation
� (commencing with Section 7000)n(Divinion 3 afthe Busineaand Professions Csale)ter
egg Net he isexempt thcmfsom and the bub fm the alleged exemption.Any violation of
Seedon 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of
not more than Bve hundred dollars($500), f Occupancy Type
❑1,as owner of Ne property,or my employees with wages an their side compensation,
will do the work and theswctum bnotimmnded uroffcrtd formic(Sec.7044,Business Required Inspections
and Professions Cade:The CanvectoYa License Law does int apply m e ns an owner of q P
p ropeny who bu Ilds ar impraws themon,end who does such work him self or through his
mon employees,Provided that such improvements Am not Intended moRered fm tale.if.
however,the building or improvement it veld within one year o(compdedon.the owner.
builder will have the burden of proving that he did not build or improve fm purpose of
sale.).
❑1,u owner of the property am exclusively convecting with licensed contractors m
construct the project(See.7044,Business and Professions Code:)The ConuactoYs Ll-
cense law does eat apply in An owner of property who builds or Improves thereon.and,
who ronin ns for such Projects with A eonttanor(U licensed pursuam in the Contractor.
License Lew.
❑1 am exempt under Sea .B k P C for this won
13700
nae Data
WORKER'S COMPENSATION DECLARATION
I Aemby arm under penalty of perjury arc of the following declaatia s,
1 ban and will maintain A CeniBesn of Consent to seIN..uin fm Winker.Compen-
on,As provided for by Section 3700 of the:Mbar Cade.for tie Performance of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation handsome.u required by Section
of the Labor Cade,for the performance of the work forwhich this permit Is issued.
Worke siCampensad @Insurace tinier and Policy nu ber artrtitr. R �C Polity XEMPTION FROM
WORKERS'
GERTIFlCO F COMPENSATION
WORKERS
COMPENSATION INSURANCE
(This section need matte completed if the permit is loroac hundred dollars(1100)
or It..)
I certify that in to performance of the work for which this Permit Is issued,I shall not
employ any person in any manner An As in became subject in the Workeri Compensation
Lawsof Glifomia.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenificate of Exemption,you should
become subject to the Worker's Compensation provision of the Labor Code,you must
0 O for ith comply with such immune.m this Permit OAR be clamed invoked.
z'" CONSTRUCTION LENDING AGENCY
I hereby affirm thathom is a constriction lending Agency for the Performance of
Cmiti
the work for which this permit is issued(sat.3097.Civ.C.)
GQ lendcfs Name ,
0 z Lender's Address
V 0 I certify that 1 haw read this Application end 31110 then Ne Above infamudon is
11v E cornet t agree as comply with all city and county ordinances and soon laws relating to
0 building construction,and hereby authorise representatives of this city to enter upon the
Lkl above-mentioned properly for Inspection purposes.
(We)agree in save,indemnify and kap harmless the City of Cupertino Against
T�q Ilabilitles udgments.ants and expenses which may in any way acme against said City
V 7 inc race of Ne 6/antinB of this permit.
Ft Al- 1 NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S R EREGULATION
• t p� B'Re-roofs
ngwurt ofas
HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will the Applicant at fume Wilding occupant nom or handle husrdous martial
As dented by the Cupertino Municipal Code,Chapter 9,I3,and site Health and Safety
de.section 25533(a)? All roofs shall be inspected prior to any roofing material being installed.
0Y. Q
W01 the eppinans or furore building accurate,use equipment m devices which
If a roof is installed without first obtaining an inspection,I agree to remove
it humdnus air contaminants u dclined by the Bay Area Air Quality Management all new materials for Inspection.
Distrin?
❑Yos Na Q
Irkgv reaf thehv�rdausmanriab inquirtmenu under CluPmd.95 a(thc Glifor
Malkin f! afetyCode,Secuam25N)3,25533md15534,lundeuNMthuirNc Wilding
does t only ban A enan4 dist it b my responsibility m ratify tie occupant of the
rey a rhich a ntpriotoiauanaarac[niR[aciroccapan[y. Signature of Applicant Date
® r 0
Owneranmhomc again pan All roof coverings to be Class nBn Or better
Community Development
10300 Torre Avenue
aC10F
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT#
SI v 6'z-a! z-3
OWNER'S NAME: PHONE # yog 59i 18d-7-
GENERAL
d7GENERAL CONTRACTOR FAX # p -7/
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
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
Owner/Contractor Signature Date
CITY OF CUPERTINO 6
S-rM TEMP POWER
$CUPERTINO PERMIT APPLICATION FORM
APN# 7��r �� a �� Date:
Building Address:
Owner's Name: Phone#:
oy 5- 9 0 ,Ya-7
Contractor: (0 c.t NJ Phone: License #:
Contact: Phone: Cupertino Business License#:
S ,It
Building Permit Info:
Elect 9
7 7-� POL,,2,— Pa
Job Description: r
Residential Commer ial ❑
Cost of Project:
sb
Qty. if
Applicable, Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING