05050042 CITY OF CUPERTINO
BUILDING DIVISION PERMIT +aC,ONTRACT(IRINFORMATIONs
BUILDING ADDRESS: PERMIT NO.
SARSCO CORP 05050042
M�AMPE)MITA AVE PERMIT ISSUE DATE
ONE: SANITARY OL NO.
RCNITECT/ENCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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P00 LICENSED CONTRACTORS DECLARATION IobD O
m I hemby af0rm that 1 am licensed under provisions of Chapter 9(commencing PPPSSS...---CCC...���(1MMgggllt1p IIt111yyy p ppp ®®
iW with Section Tot111)of Division 3 of the Business and Profession Code.and my license,is L 9 ��■
DoIn
in full Tomeand cffen' IJ P tl 1tM��
J�? License rmli ue.x�) � TEMP POWER POLE
�–p Dale, Contncmf � AR. !n
~mj ARCHITECTS DECLARATION
I understand my plans shall W used as public mxords ,s 2005
JyU L
;gI License)Professional
3 OWNER-BUILDER DECLARATION ss rs��®�
n 0 I herchy.Giem that 11. exempt fore the Contmaor's License Law for the {Np�In{ ljT'�
0o follwhnwingmason.permit
7031.5.Business and improve.
dvionx Code:Any city of county (Y/aar�gaJ/_
S m which m9uims a permit to construct,alter.impmw,demerit u or repair any xwmum
prior m its issuance,nuarequire IW applicant for such Mrmil to Nes signet sutemcm
EE< that heisliccnmJpursuvnuothe previsionsofthe Convector'sLiucnseLaw(Chnpmr9 Sq. Ft. Floor Area Valuati ❑
z1– (commencing with Section 7")M Division 3 of the Business and Professions Code)or
i that he u exempt therefmm and to hasis for the alleged exemption.Any violadon of
Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of er Occupancy Type
not mom than fin hundred dollars(BRIO). 3 5 Yt 1711Y3'Y�. 0 0
❑I.as owner ofthe property,or my employees wish wages as dhcir sole compensation,
will on the work.and Ne slnctms is not intended m.1femd forage(Sec.9041,Business
and Professions Code:The Contractor's license law docs not apply in an owner of Required Inspections
property who builds or improves thereon,end who does such work himself or through his
own employees,provided Unlatch improvements are not intended muffered for sale.If.
however,the building or improvement is sold within one yev of completion,the owner-
builder will haw the burden of proving that he did not build or improve for purpose of
❑1,as owner of the pmpeny,am exclusively contracting wish licensed contractors to
construct the project(Sec.2044,Business and Professions Code:)The Contncmr's Li-
cense Taw does not apply m an owner of property who Wilds or improves thereon.and
who contracts for such pmj.cu with a contractor(s)licensed pursuant in the Contractor's
License Law.
❑I am exempt under Sce. .B&P C for this mason
Own., Dam
WORKER'S COMPENSATION DECLARATION
I hereby aRno under penalty of perjury on,of the following declarations:
1 haw and will maintain a Certificate of Consent to self-insure for Workces Compen-
tion,ns provided for by Section 3900 of the labor Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Workcr's Compensation Insurance,as required by Section
39W of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are
Carrier: I –osV+ Policy No.: D —&X' 421�O
CEM CA OFEX PIONFROMWORK S'
COMPENSATION INSURANCE
(Thu section need not W complmW if the Permit is forms,hundred dollars(SIM)
or lest)
1 certify that in the perromtanso of the work for which this permit is Issued,l shall not
employ any person in any manner m as to become subject to One Workeri Compensation
Laws of Ci lifomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
W.mne subject to the Worker's Compenalion previsions of the labor Code,you must
.JO forthwith comply with such provisions or this permit shall he deemed mvoked.
Z' CONSTRUCTION LENDING AGENCY
Ihereby from that lhcrc iso construction lending agency In,dnc performance of
a the work for which Russ permit is issued(Sec.3899,Civ.C.)
Q Lender's Name
6.
oz Lender's Address
V P I ttNfy that I have mad this city
and oun and sum Net the above ws oohing u
U.U building 1 agree to comply with all city and county otatimi of and sole laws relating to
V above mentioned
construction.pm.and for
ae tiom roposexnulivrs of this city m enter upon lM
r W shove(W)age to show fo damnify an keep ha
(We,)agree to ave,indemnify and kith harmless thew City ofr itinuts against
h in
of U.mints
grading oapersscamit. may in anywayaccrue gainsl said City
V z in cone9uencc of the gaming of Nis permit. /
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dates9 TX��/ j
SOURC ULATIONS. ��/
�� -- / Q /�oIT' Re-roofs
Signator.of ApplicanllConlmctor Date,
HAZARDOUSMA LSDISCLOSURIS Type of Roof
Will the applicant or future Wilding am....I smm or handl.hwar ito s material
m Oeftocd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ale,Sccuon 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
oYn TIO
Will the applicant or future building occupant usc equipmentor devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haxnrdous air contomimmis a Jcfnce by the Bay Arca Air Quality Management all new materials for inspection.
istriCl? ..[[
Flyer ICI Nu
I have mal the hvardhws materials mquimmcnu unJ rChapmr6.95 o0W Califon
nu Hnith&Safety Code Sectau25505,25533wdn534.lundersund JuliftW Wilding _
Jles not currently ham a tenant,Rua his on,re.,usibility m onto;Ne,amupant of to
mquimm.nu which must be mel peorro issuar¢c.fa Certificate ofac, ancy. Signature of Applicant Date
-I; nr(''— All roof coverings to be Class"B"or better
Owocr ramhorixedagent Date
CITY OF CUPERTINO
S TEMP POWER
SCUPEkTINO PERMIT APPLICATION FORM
APN# Date: 9Ds
Building Address:
Owner's Name: Phone#: o o j b
At'
Contractor: Phone: e License #:
S
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Contact: Phone: Cupertino Business License#:
3 �Do
Building Permit Info:
Elect Zl—
Job Description:
Residential X Commercial ❑
�Rw o Pte/ O
Cost of Project:
Qty. if
Applicable Fee rD Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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