05110026 --------------------
CITY OF CUPERTINO sx •"+''^f*x .. �" � �"' Y '� " '` �''''' >r"
BUILDING DIVISION PERMIT
BUILDING ADDRESS: G T JORDAN ELECTRIC INC """x'05110026
20400 MARIANI AV
R'S NAME: PERMIT ISSUE OATS
DADE BEHRING 963 CHESTNUT
NE: SANITARY NO. CONTROL NO.
(408) 292-2388
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
0 0
jOo LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hcmby silicon that 1 w licensed under pmvieiau of Cluplor 9(oomanOWIRg p
with Section 700 0 of Divlden 3 of the Budncuatu Refesatoes Code,and my Became ta
'z "���l(one$noOffe. Lk � Z� 3 RELOCATE ELECT. PANEL (P5B, P5C, DP5)
Dakcomracmr / e CONTRACTOR: G.T. JORDAN ELECTRIC ($126643)
7 an C used
DELLA ON
� I underatanJ my plena shallall be bu usA u public records
5 ud� Licensed ProfeWunal
OW NER-BUILDER DECLARATION
E 1 bunchy sDlrm that I am esempt from the Contruror's Ueenm Law for the
a O following moon.(Section 703 1.5,Business and Professions Code:My City Or county
3$ which requires a permit to onmuuct.aller,improve,domultah,or repair try locum
iL^ prior w its issuance,ala res brog the applicant forsuch permit m file asignod aukmem
—Q
that he I.licensed Pannonia m de provisions of the Contractor.Limens Law(Chapmr 9 Sq.Ft.Floor Area Valu;$$W 000
O� (commencing with Section 7000)ofDivision 3 of the Budneu and Professions Coss)of
3 that M Is ancmpt sherchrom and the basis fur the alleged uampdon My Notation of
Secdon 70713 by arty applkmt for a permit mbjew the app0aat to a civil porosity,Of APN Number Occupancy Type
rot¢ort dsen five hundred dollars(5500). 31622018 . 00
Q I,u¢once of Uk pteperry,a my employ¢NW wages u Ulo'vmk ampwadon,
wiadotheworkaMdxnmmumiaomismndedmO@rdfwuak(Sec.ION,Budrcaa Required Inspections
and Pmfedom Cede The Contracurn Licesm don COL doCot apply m M Owner of q p
property who builds or i mgow i Neuron,and who does ouch wort himself m t MOm1b hit
Own employees,provided that such improvement;ma natimedd uraQeed fer WCL U,
however.the building or Mprowment kmhi widtin me you ormmponen,the camr-
huildu will have the burden of proving cut he did rot build of improve far Purpose Of
❑1.as Owner Of the property,am exclusively commming with limmaed antrseaa lo ��
come=the prolets(Sec.7014.Business;and Pmmadom Code:)The Cmtrcw'a U• -
CO.Law does nu apply m an weer of propenywhe builes a hapw
ro ,thereon.and, A
who common for such projew with a contractor(s)Ikelmd Panama be the Camimmil Ya
Lice.Law.
❑lammemptundw See. ,BkPCFurth1,.m
or Data
WORKER'S COMPENSATION DECLARATION ,v
1 hemby aRim under penury of perjury one of the folkwing d lta om:
I ham ad will mdnuin•CudOcau*([hese¢¢Code.ore far WOrkds Coapts-
¢don,u ptovitled fm by Sation 7700 of the Labor Cade.for the pedmmua of dlo b
work for which thin permit k iuued.
❑I haw and will maintain Workeh Compensation Imaraae,es required by Semmes
7700 Of the labor Code.for the parfmmance of the cork for which thta permit u i.".
My Workers Compensationpetlomama carrier and Policy nar"-
Grtier, DF/I'trXYGtIS. Policy No.;
CEICfIflGTE OSA FMPfION FROM WORKERS
COMPENSATION INSURANCE
(This scorn need not bu eamnpkud U the permit 4 farm hundred de0an($100)
or los)
I certify that in the performance of tie work for which this permit is Issued.I"I rot
employ any person in any ancaru as On barman subject In the WOtkCrf C=Prsuadw
Laws of California Dam
Applicata
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject to dm Workers Compensation provuiom Of not Lmer Code,you aunt
.J 0 forthwith comply with well Provisoes Or this permit shall be deemed mucked.
z' CONSTRUCTION LENDING AGENCY
[—i Ihereby M.that than lea cormracd.lending agency far tht ismfureence of
p:> tht work for which this permit 4 wood(Sec.5097.Civ.C.)
4 0 Lenders Name
z Lenders Addreu .
V O I aNfy that I have mad this application and scum that the above IaformNon Ll
D, cortex I gree to comply,with all city and County Ordinances ad state laws relating In
O building construction.and hereby uthodm representatives of this city to color upon the
D.,W aMve-mendoted property for inspection pure s.
�Lg.r,h (We)agree to save,indemnify and kap hatmlen the City Of Cupertino agdml
i—r fa/) Iiabilidn,jdgmmulcasmandexpeasea whlchmaykuywayaasaaNmisaid Chy
V Z in consequence of the gwdng of this pvchh.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR DNS Re-roofs
Si m —417 NA=US MATERIALS DISCLOSURE DataTypeof Roof
WIII tis applicant orfutum building occupant nam orludlc hacandous m&WW
as dcab d by the CupeNno Municipal Code,Chapter 9.12.and tin Health and Safety
.Sod¢25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
13 yes
Will the applicant or Future building occupant us equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hvardous air contamina^nu"a defined by the Bay Ma Air Quality Management all new materials for inspection.
District?
V 6
pYes
I haw and the hmrdtms mamdals mqulmmenu underChapmr6.95 afthe Callfer-
nit HCCIth k SaletyCod,Secdom25505,b533 ud2.U34,1.nd nand thuirelo building
does not currently hew a lonul this it h my responsibility to notify the eccup al of the
myulmmcn Met prior missuance of.CcrcfhateofOcapanca. Signature of Applicant Date
JAA o ncr ar nu ter Dam All roof coverings to be Class"B"or better