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04030162 '- CITY OF CUPERTINO BUILDING DIVISION PERMIT ! BUILDING AD00.ES5: PERMIT NO DWK CONSTRUCTION o4030162 - R'S NAME: PERMIT ISSUE DATE ON CH SANITARY OL NO, ONE: ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUME MECH a 0 0 0 o o LICENSED CONTRACTOR'S DECLARATION Job Description thereby ) fcNal1amftheBuunderprovisionsofChepa, ,(commencing F'NALE® ^� with Section hem D/lt)nf Division elicensed Business mal pr Profasiof hader9(co(commencing a in full force and effect License 1 a Lie.# 0197 TEMP POWER POLE °_ `°°DECL MAR 1 8 2004 ARCHITECTStra.9 DECLARATION 1 understand my plans Mall be used as public records U Licensed prettiest enal BUILDING OWNER-BUILDER DECLARATION I hereby affirm that 1 1. exempt Isom the Contractor'sCoe:Any c Law for the HN O following moron.(Section]fl]1.5.Business and Profcssium Cale:Any city lir county $(v which=qui=s a permit to cnnswct.alter,Improve,demolish.or=pair any sorters= F Z< o prior m its issuance.also"u res the applicant former ohnit to file a signed So amcnt £ ° that he is licensed purauanlmthe provisions oftheContncesn'sUcanse Law(Chapter 9 Sq.Ft. Floor Area Valuati y $ (commenting with Section 7")of Division 3 of the Buaiecas and Profession,Code)or Nat he Isexempt Nemfrom and the hies for do alleged exemption.Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant m a civil penalty of 3'ptPj1, >g�@rp O Occupancy Type not mom than live hundred dollars(S500). ❑1.M owner of the property,m my employees with wages u their sok composition. will do the work,and the sWcture is not intended or ffered for We(Sec.71144,Business and Professions Cade:The Conmomes License Law docs sat apply or an owner of Required Inspections property who Wildsmimpmvm therson,amdwhodcas such work himselforthrough his ownemployces.provided that such improvements are net intended moRe=d forsee.if, however,the building or improvement is Bold within one year of completion,the owner builder will have the burden of proving that he did not Wild or improve for purpose of sale.). ❑1,as comer of the property,am exclusively connecting with licensed contractors to construct the Project(Sea.7044,Business and Poefmdons Cade)The Comments's Li. came law docs not apply to an owner of property who Wilds or improws themon,and who contracts for such projects with a contractor(S)licensed pursuant to the Contractors L'anae Law. I are uempyt un[d�r see /y Bk PC for this moan Data ^U WORKER'S COMPEN TION DECLARATION I hereby of ion under penalty of perjury one of the following dealuado ce I have and will common a Certificate ofConsenl to sel6insure forWorlon s Compen- sation,as provided for by Section 3700 of the labor Code.for dm performance of Out work(or which this permit is issued. - ❑1 have and will maintain Worker's Compensation InsWantce,u=qui=d by Section 37oD of the labor Code,for the performance of the work for which this permit is Issued, My Wark es Compensation Insurance carrier and Policy number am: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thsuctimh need notbecomple=d ifthe permit is formalouideaddollau($100) or less.) 1 cenify Nat in the performance of dm work for which this permit is issued,l shall not employ any person in any newer so as m become object o the Workers'Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:If.eller making this CeniOate of Exemption,you should become subject in the Workeh ComPerissi provisions of the Labor Code,you most 'z forthwith comply with such provisions m this permits hall be decm°d rewkctl. ti O CONSTRUCTION LENDING AGENCY (—i I berebymTrm that them is a commuctlen lending agency forth,perfmcancc of (Yi 7 the murk for which this permit is sued(Sec.3(197.Civ.C.) QLender's Name Z)z Under'sAddress V 1 cenify that I have read this application and state that the above information is lg..F correct.l agree m comply with all city and county ordinames and mute laver mlaling to - V building construction,and hereby mahadae representatives of this city tnenteruPnn the 0 W ahovcmenlioned property for inspection purposes. fY (We)egme to save,indemnify and keep ha=tless the City of Capons against cn Iiabilidesjudgmemu,costs and expenses which may in any way accrue against aid City V z in conamp ence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY ITH ALL NON-POINT Issued by: Date OURCE REGU'j,ATIONS. ^/ Re-roofs tore of AppliamlConbacmr Data .G HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupamstom or handle hnmdous material M di fined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety can,Section 25532(a)T All roofs shall be inspected prior to any roofing material being installed. ❑Ym rRNu Will tic applicant or f�7�"u1m building occupant taw equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit harardnm air contaminants as de0ncd by Ne Bay Area Air Quality Management all new materials for inspection. Martel? - ❑Yes I have read the hnsfdsua mammos requirements under Chapter 6.95 of the Califor- nice HaiO&Safety Cedc,Suctions 25505,25533 and25534.I undeutsnd dwifNc building Jens net currently hove a=nano Nm it IS my operability to notify the aocupanh of the requirements which me be=et prior m user f a Certificate of Occupancy. Signature of Applicant Dale 7� "�� All roof coverings to be Class"B"or better Owner or amhanweda agent �Daic CITY OF CUPERTINO ,&g7j�% TEMP POWER �- UPEIOF INO PERMIT APPLICATION FORM APN# 7.,_ / ? O � Date: Build' Addr ss: /§,n§I ZZ Aiko- Owner's Name: Phone#: GHe as)66,5"—1 �o Contractor: Phone.. License#: D/J ons fi'?c �� 39-0963 a &z00217 Contact: Phone: Cupertino Business License #: 'rFf aw/srs Cf-tGt Building ermit Info: Elect Job escription: T-&-iNp (U/sW Residential ommercial ❑ Cost of Project: Qt"'If li ble Fee ID Fee Description Fee Group BTEMP Temporary Power ELECTRICAL PERMITFEE Elect. Permit Issuance ELECTRICAL BUSLIC Business License BUILDING 2qf