04040047 �7,� 7777 7777,7'7�11
CITY OF CUPERTINO
I
i BUILDING DIVISION PERMIT CON
RU
DD S PERMIT NO,
BUILDING ADDRESS: JW ENTERPRISES 04040047
OWNER'S NAME: PERMIT ISSUE DAM
ONE:CHICH WT�T� 1689 MCRrT4 AVE SANITARY it.4 8/'2 NtOl,NO.
ARCHITS17DENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MIRCH
woo LICENSED CONTRACTOR'S DECLARATION Job Description
I briaby affirm that I am licensed under provisions of Chapter 9(commencing
with Sticlian 7")ofDivision 3 ofLhc Business and PrOficsildhor Code,and my license is
in full to=and effeel. FUNALED
TEMP POWER POLE
SEE License Cl.a Lic.
z Dhae-commium,
ARCHITECTS DECLARATION
I understand my plans shall M used as public recood, APR 2* 2004
D�u
Licensed Professional
I t OWNER-BUILDER DECLARATION
i�z I hereby affores that I am exempt from the Contractit's License Low for the BUILDING
mC following mason.(Section 7031.5,Business and Profession Cork:Any city or county
which actimucir.Permit to consumer,ititu.improve,demolish.or repair any structure
pow to its issuance,also requires me applicant for such permit to file a signed statement
mai he is limmeed pursuant to the provisions oftlic Conumbit's Limman Law(chapter 9 Sq.Ft.Floor Area Valuatio
(cmarrounicing with Sord..7").[Divishor 3m`the Brerinessual Professions Code)or
bar he Is entrumpt therefrom ad the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the lififfirarl 10 a civil penalty Of 3 2"*NJsbI0*qr0 0 Occupancy Type
not mare than five hundred dollars(M).
E]1,nowent arthe property,ormychiplayars,with wages theirselacormicanumn.
will do the.,k...d 0e structure is not intended or offered fariefle(Sm.7044,Business
and Professions Cardei The Contercuin's Limi Law 4ors oat apply to an Owner of Required Inspections
property who builds or Improver Banner,and who does such work lonessilforthrough his
own employees,provided thatsuch improvements Ana MiLintanded oroffided forests.If,
however,me building or Improvement is cold within am year ofcamplefier.the Owner.
builder will have me bond.n of proving that be did net Wild mr Improve to,propose of
atic .
1,ar;Owner of the porperty,am exclusively contracting with licensed contractors to
an =I the project(Sec.7014.Brain.and Profession,Code:)The Compromises Lt.
came Law does not apply to an owner aproperty who wilds or Improves thereon,and.
who contracts for such projects with a commanctor(s)Ilecesed pursuant to the Cormaticloes
License Law.
0 1 am exempt under Sam may
08 PC for .
0,6.4 Dam
�/f�-
tR S'COMPS NSATION DECLAR10
�I h W under
penalty of perjury one of the following dectarmadome
have may-'
:mawill'oodrium:CanifiessurofConscat toself-imam for Worlau'sCompan.
'cation,as provided for by Section 3700 of the Labor Code,for%a performance of me
work for which this permit is issued.
n I have and will maintain Worker's Compensation Insurance,as m4uimd by Section
3700 of the Labor Codo,for the performance of the work for which this Forest,in bound.
My Warlaces Compensation Insurance carrier and Policy number are:
Cartier: Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cnissecticir arcedmit thic cruni time pi 1e forms,hundred out[ars(llffl)
or less.)
I certify that in the perfoort of the work for which do.permit is based,I shall not
employ any person in any thereof an a M become subject to EneWorkers'Compensadon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If.after making this Conifers,of Exemption,you should
become subject to the Workeri Compensation provisions of the Labor Cook,you must
Z learti comply O,mh such provisions mr this permit shall Iss,deemed revalmd.
.Zi0 CONSTRUCTION LENDING AGENCY
14 1 hereby afford that the.is.construction leading agency for th,part.....n of
> the work Car which this permit is issued(Sm.3097.Civ.C.)
Leader Name
0-E
D z LeadersAddrar,
U 0 1 certify that I have mad this application and soon did,the itimve information is
Pmeant.I agree to comply wit all city and county ordinances and state laws miming to
Wilding construction,and hereby someone mpmscnMfiws of this city 10 under-Me the
abovc-mentimand property for inspection purpooses.
LL (We)agree to save,Indemnify and keep harmless the city or Cupertino against
no's and examines which may in any wa of
U Z in consequence of ran g.14 this pentraft.
"' APPLICANT UNTIE DS AND 14 INT
1-
c,2 liabilities,judgmints.c y see=against mid City
ILL COMPLY WITH ALL Issued by: Date
Re-roofs
Signature&I'ApplicanitCmiusietch,3 Dam
HAZARDOUSMATERIALSDISCGO-SURE Type of Roof
Will the applicant or rut=building KimparuStOro or handle brecandous nouturri.]
defined b the Cuiparomi,Munici I Code. after .2.and tim Health and Sadinty,
CUO.marti'o'.25532(.)' All roofs shall be inspected prior to any roofing material being installed.
oy. '0
Will the applicant alone aiding Occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
District'hazardous air contaminants defined by me Bay Area Air Quality Management all new materials for inspection.
District'
0 ym nN
y
I have mad!toe harardrim;armiumlser,prinimannumide,Chapter 6.95.ftho Califor.
mitHisifths,Sfct,c.&,Vcdons Z5505,25533 and 25534.1 understood thatifthe building
Jos not currc�thlly ghn a mxn,�,011 L
ic in
mil vhic in theater asuarm.f.comfl, f y ignature of Applicant Date
than All roof coverings to be Class"B"or better
Oarainmr.wit.d9dagent rs
d agent
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDIS: /d//D/19,AW P „tN o r?a�� /ERM
OWNEWSooNAW�. PHONE^1 (� 8
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
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
SepticT tj N L
Sheet Me
Sheet Rock
Tile
Ownerloo Signature Date
r
CITY OF CUPERTINO
;M, TEMP POWER LI)
CUPEkj[NO PERMIT APPLICATION FORM
APN# �2/' ! QD4 � Date:
Building Address 1'1'1/9Nl ,1,>4Z ?W li�JO
Owner's Name: (f1 A�/ / [Cq Phone#: 8 z
Contractor: Phone: License#:
Contact: Phone: / Cupertino Business License #:
Building Permit Info:
Elect
Job Description:
Residential Commercia ❑
Cost of Project:
Qt .
A lice Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
PERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
X93 ��