04080119 CITY OF CUPERTINO *'� h '
BUILDING DIVISION PERMIT TRACTMINF,ORMATION
BUILDING ADDRESS: PERMIT NO.
K & M DEVELOPMENT INC 04080119
OWNER'S NAME: PERMIT ISSUE DATE
E:
SANITARY 4:3OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELO PLUMS MECH
13O
LOp LICENSED CONTRACTOR'S DECLARATION
I hereby affntm tbut I am IlCoved under previsions of Chapter 9(Commencing
a� with ScaionlIXDyof Division3oftKBusinevand Pr.fcui...Code.andmyliccnuis INATLED
H L full fora and c"
z Licenu ClMs Lic.,1 6 4y�'� TEMP POWER POLE _
Dam Contracmr AUb ti 1004
q CTS ON
L T
a Iundcnun m Ian ,hal eta is months
°0° BUILDING
g0 Licensed Profc NG
b OWN UI ECLARATION
2 Si I hereby,(Sect on I am exempt from the Contractor's Co License Lew for the
too followhich re recon.Permit
]Ins.r Business and improve,
Code:Any city scounty
which requires a permit to arms the alcor,impmm,demrviii t m repair any statement
poor mimlIIYNRJIWmGWma pmvisphanl for Wehpermil lLiabsele a Law(ned rhapterl
< that puntrant to )of Division othe f
usinar'Wanulsw(C Code)
Sq.F[. Floor Area Valuation
t] Unit M ise(commencingwithSanson lan(p of Dive,for da A Business and Profession.Any vi late.or
wy he 7 campy dmrtfrom and the pCo far be alleged Corruption.to Any it PHtlon of
nSectiono,..7031.5 five
any applicant for•permit subjects the applicant a civil Penalty of 3 4\TV4,No1ber0 0 Occupancy Type
not mom than five hundred dollen(ESon).
❑1,a owner of llm pmprny,m my employees wi0 w guu da:b mla compenudon,
will do thework,and the ewmure is not mounded.roQered Parole(See.7016,Business
and Profnsslons Code:The Conuacmr's License Law docs net apply to an Owner of Required Inspections
property who bu ilds nee improves thereon,and who dueaueh work himu If or tluough his
own arPlnyou,provided that such improvements am netimmnded aro@mA ferule.If.
however,Ne building or improvement is sold within one year of completion.the owner.
builder will love the burden of proving that he did not build in improve for purpose of
aic.).
❑1,as Owner of the property,am esclusively contracting with licensed maulers to
coatmm the pmjcct(Sec.7044,Business and Profusions Code)The Contr cmri Li. .
ccnu law docs not apply in an owner of progeny who builds or improve thereon,and
who contracts for such projects with acomrutor(s)licensed person in dm Contraction
License Law.
0 1 nn uemp,under Sec. .B&P C for this meson
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hemby aRren under penally of pujury one of the fallowing deelaatioes:
eve and will maintain a CeNOcam of Cenunt m u f-inure fm Worker's Compen-
on,u provided for by Batton 37M of Bre labor Cade,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Wekeh Compensation Insurance,a required by Section
3100 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's compensation Insurance coria and Policy number am:
Cartier. //''g�7,e.W. Paltry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMs union need nmbc completed don,permit is forme hundred dollars(SIM)
or loss)
I certify that in the performance of the work for which this Permit is maned,I shall not
employ any penin In any manner an as in becomesubjcet to the Workers Compensation
Laws of Califomin Dam
APPlicaue
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Cede,you mum
., forthwith comply with such provision orthis rcmtit shall M deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
[-+.N_. I hereby alarm the them is a Construction lending agency for du:pararmance of
!Yi the work for which this permit is issued(Sec.3097,Civ.C.)
Lg1 0 Lender's Name
0.z Lender's Address
U 0 1 artily that I have mad this application and sum Na the above information is
I[.P coma 1 agree to comply with all city and County ordinances and sum laws mining in
DU building construction,and hereby authonan representatives of this City to enter upon the
If7 above-mentioned property for Impaction purposes.
G (We)agree to ave,indemnify and kap harmless the City of Cupertino gout
In liabilities.judgmeno,costs and expenses which may in any way accme&gamut mid City
U Z in consequence of the granting Of this permit. /�
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date (/ =C✓_
SOURCE REGUL
4� ? Re-roofs / 7
Signa lure of Applian n pa [ J
OUS ATERIALS DISCLOSURE Type of Roof (_
Will the applicant Uding occupant more or handle haallous material
as defined by the Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
Code,Section 25533(a)n All roofs shall be inspected prior to any roofing material being installed.
Yu %t7 No
Will the epplicany or future building occupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
henNnu air Conumirnns u termal by the Bay Area Air Quality Managcmcm all new materials for inspection.
ict7
[j you N"
1 have mad Ne huardous mamnab rcquin menu under Charter 6.95.(the Calif O.
nu Ranh&Safety CoM,Section 25515,25533 and 35534.1 understand that iflhc building
dna non cunendy bum,•mnam,out it u my mapoaihility in or,on attup.,of the
mquimmentswhw be map' veoccofa Cenifcamo(Oceup
ySoy Signature of Applicant Date
Ownororauthon, a t p e All roof coverings to be Class"B"or better
Zmn
CITY OF CUPERTINO
TEMP POWER cry
"UQTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
l<0/4/ L ZC3/a.Jo,✓ �2
Owner's Name: Phone#:
/�.�1/w /n/✓Z;r .y s GLC
Contractor: 4 Phone: License
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Contact: Phone: Cupertino Business License#:
A-lldf� 40 (9.. 390• S/ Z-7
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Building Permit Info:
Elect
Job Description:
Residential Commercial ❑
Cost of Project: ' ,
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As
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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