04090254 .:,.CITY OF CUPERTINO -T�:.aate�s-,,��.��T ��•v -
BUIUDINC'DIVISION- �E1LLY111 . ,.:" UN RAC ,R�UI 1�Itr1 kU .
s.•j,..,,, h r ix & ,� .
BUILDINGADDRESS: BAINS DEVELOPMENTS PERMrrN904090254
OWNER'S NAME: PERMITMUEDATE
DOMIN
ONE: - SANITARY O: CONTROL NO.
ARCHITECVENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
40G LICENSED CONTRACTOR'S DECLARATION Job Description
V 1 hereby affirm that I am licensed under provisions or Chapter 9(commencing
with Section 70001 m'Division 3 of the Business and Prefculons Cod-,and my license is
in fall force and effect. TEMP POWER
iLicense Class Lie.p
M
Deu Contractor-
ARCHITECTS
amfamer /!
Aan DECLARATION \�\
1 understood my planss shall shell W usaJ as public records
�yU
;g0
Licensed Professional
OW NEm BUILDER DECLARATION
d 0 I hereby.(Sant on 1 1, exempt from the Conusctm's License Law for fey
po following reason.Permit
8Businessalter.Improve,
Pmfceions Cod-:Any city nr county w
K$(Li which requires o p-rtnit us,umsthconstruct,epee Impmw,demolish, file
mash any murmur- -
Fi< prioress its iensedp rsuamquircs lWvision Of forsucthe Cohpermi'mi..n.gacdsumm-m
femWts licensed purstion700)00)of Divionsof feeeBusinssand Preflaw(C Cods)
Sq.Ft.Floor Area Valuation:
ERE
(commencing empthomtinnt and
basisofr the
theege axe endon.Any
Code)or
., Nat W u exempt there(romsnd dte bnsu for Bte allegctl exemption.Any vloladon of
Section 7031.5 by any applicant for a permit subjects the appluam to s civil Penalty of 3 492-01 erb 0 Occupancy Type
not more Nu five hundred dollars(SSW).
❑l L o owner of and
prosaduc or is employcca with wage r theh Sole compensation,
will do Newons andie ice Contistotimenticdor e .Baredformate(Sec.]014,Boniness
and Professions ldsdc:The Contractor's License Law dons or apply lf an owner of Required Inspections
property who builds vi improves discount.imprand who das.ch work himselfor his
own employers,lding aetl that such improvements arc notimsMW m leeutl fOrUI&the Own If.
however,Ne Wilding or improvement is Sold within one yeas of completion,theOwner.
of
builder will have the burden of proving that he did not Wild or improve for purpose of
salc.l
N.as owner of the property,sal exclusively conu.ting wife licensed emarnot rs in -
const ocr th project(Sec.7044,Business and professions Code:)The Contractors Lt.
rd
law docs not apply to m.teeter of property who Wilds or Improv feereon,and
who contracts for such Projects with a costd curs)koem, Ne ComracmYs
LicenseLaw. //
� der.am exempt unsef ,Bdk PCF. its P
to
./- �,...
WORKER'S COMPEN ATION�iCI.A_RATIa
1 hereby arm under penalty of perjury'6f Ne following declarations:
I here and will maintains CcniOcamo(Conunt m self-insurefor Wmloo'sComp-n-
sadan,ns provided for by Section 37W of the labor Code,for fee performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3]W of the Labor Code,for the performance of the work forwhich this Permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Palley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE t
(Thu motion need not W mmplctad if the Permit 1s for one hundred dollars,ISI W)
or less.)
I certify that in the performance of the work for which this Permit u lamed,l shell not
employ any person in any manner.as to Wmmc subject m the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.IL after making this Cor ifica¢of Exemption,you should
become subject to the Worker's Compensation provisions of fee labra Code,you must
7,. forthwith comply with such provisions or this Permit shall W deemed uvokcd.
r O CONSTRUCTION LENDING AGENCY'
[-a Ihereby affirm that there is a construction lendingag-ncy In,the performance of
IYr 7 the work for which this permit is issued(See.3M,Civ.C.)
WL Q Lender's Name
n1. z lender's Addreu
V Q I certify Nat 1 have read Nis application and sum that the aW ve information is
{T.H correct.1 agree to comply with all city and county ordinances and sure laws relating to
C(, building construction,and hereby sufertroO repmsenutives or this city in eater upon fec
W above-memi...d property for inspection ropous.
gy (We)agree to save.indemnify and keep humless the City of Cupertino against
fn liabilities,pdgmcma,costs and expenses which may in any way....against said City
V`l in consequence of the granting or Ibis per
G7 APP (CANT UNDERSTANQSS AND ILL COMPLY WITH ALL N N-POI Issued by: Date
SO E.R TIONS. t7
Re-roofs
Signature Applicesnt/ moscur 1 - Date
HAZARDOU ]AIS DISCLOSURE Type of Roof
Will the applicant or future build occupants.m or handle hux lous material
as defined by the Cupenino Municipal Code.Chapter 9,12,and the Health and Safety
.mLCod-,S bcm
25532(.)? _ Jn All roofs shall be inspected prior to any roofing material'being installed.
❑Yes �N
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harardous air contaminants as defined by the Bay Area Air Qualpy Management all new materials for inspection.
District]
[3 Yes [71*
I have mad the hvsah)Zaudais requirements under Chapter 6.95 of On,Califor.
nia Health h SafmyCode,Sections 25th 11-111 34.Iumiersund featifdm Wilding
does not curen0y how a¢none the l is m rcaponsihilityNP
rets' ichmua�t=demi caofaCedaSignature of Applicant Date
ow r uthorixcJ agent All roof coverings to be Class"B" or better
' Community Development
at.
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408)777-3228
�UPERTINO CITY OF Fax(408)777-3333
BuildingDepartment
JOB ADDRESS: PERMIT# t0 ¢ n
-2-2 p YJ
OWNER'S NAME: oat /w C PHONE #
GENERAL CONTRACTOR: 5 1 FAX # u e -
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the fo owin 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
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signatd4Date
1
CITY OF CUPERTINO
Sn TFtvIP ®wER zf ° z f
ICUPEkTINO PERMIT APPLICATION FORM
APN# 3 / 2 Z Z J(--_ Date: �� 7
Building Address: 7�
:)-z o r, �A
Owner's Name: �p Phone #:
o " / vJl-C: � p 4e6 � �� — o ?77
Contractor: Phone: License#:
BAIN#S t6 ±- 3
Contact: 8hone: Cupertino Business License #:ala 77 G °3z4-
Building Permit Info:
Elect
Job Description:
Residential i Comm rcial
Cost of Project: I
Qty/A
-Apqi4b Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
2763