03050118 (ARCH=�G]�ER:
OF CUPERTINO
LDING DIVISION PERMIT CQNTRACTdR INFORMATION
ADDRESS: PERMIT NO.
JAMES MA 03050118
Er, PNGE AVE AMPERMIT ISSUE DATE
10420 ORANGE AVE 05/27/2003
2 MA SANITARY NO. CONTROL NO.
TENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
LICENSED CONTRACTOR'S DECLARATION Job Description
by strum Nal 1 am licensed under previsions of Cbrep ser 9(commencing
7")of Division 3 of 0u Businw and Professions Code.and my licenseis
and effect
�z License Class uc.a
TEMP POWER
Dam Contractor FINA LE13
ARCHITECT'S DECLARATION
1.M.m.d my plans shall be used u puhlic record,
G
' JUN 0 6 2003
p Licensee Professional
3
OWNER-BUILDER DECLARATION
ZO f 1 hereby affmm that 11. exempt from the Cssions o License Law for the
ZOO following uires a (Section 7 Coon.; Business and ow.de ens Code:Any oily or county BUILDING
$ which rtqui="permit reennnme4 mlicimprove,demolish,fie-repair gmy,Wnure
-Z� prior m.l lensed p else ntquite the appliant fon"h permit m ice se Lae(tLtemcnt
(?5FFo (commencing
comma licensed pungent to the pmvisionsof othe fthe Business
Profeaw(Chapter 9owin, SQ.FI, Floor Area C5al OI100
C d$ ffig he n exempt therefromon And
the basis for the al eged cu and on.Any
Ction of Y o
It Nn he b exempt therefrom and Ne basis for the alleged eumpllon.Any vlolNion of
Section 7031.5 by any applicator fn a permit subjects the applicator to,civil pcnatty of Occupancy y TyP
.at mom than five hundred dollar,(Mr, 3 ��elb0 araC e
❑I,as owner of the property.or my employ=with wages As their sole compensation,
will do the work end themunure is net intended or o@red for sale 704/,Business 103 - UFER Required Inspections
acrd PmfeWom Code:The Convector's Limnse Law d=not apply a an owner of q ns P
property who build,or impro s;flutown,and who d=s"h work himselfor through his 304 - ROUGH ELECTRICAL
Own employ=,provided Nu such improvements art not intended motioned for We.If.
however,the building or improvement is sold within one year of completion,the owned
builder will Mss the burden of proving that he did not build or Improve for purpose of
sale).
❑1,As Owner of the property.am uclusively contracting with licensed"ntranirs so
construct are p.j.a(Sec.70aa,Basin.and Prof=idle Code:)The Contractor's Li"
cense Lew does not apply to an owner of progeny who builds or Improves Iherton,and
A o contnea for ouch projects with i eonlracmrW Iimmd punuanuo tin Conuaciaeg
nse Lew.
lamaemptuu Cars"". .Bk PCfarthisaaeen
Own
//"`' \ 1)' so
so 7 3
WORKER'S COMPENSATION D CLA TION
/s I hereby affirm under penalty of perjury orc of the following declarations:
I havemd will maintain a Certificate of Consent m self-inmre for,Worker's Compen-
sation. "
u provided for by Section 3700 of do,Labor Code,fm the perfamomen of au
work for which Nb permit is issued.
❑1 have and will maintain Worker's Compensation Inaga nil,as required by Sccdon
3700 of the labor Code.for the performance of the work fm which this permit is leered.
My Worker's Compenalion Insurance ender and Policy number am:
Carrier: Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
MIA motion"ed not be completed hills,lemur is[.a.hundred dollars(SIM)
or less.)
1 mnify that in the"PImes"of the work for which this pmelt h bound.l shall nn
employ any person i ny manmr sn as to b omen hjectm NeworkeKCompemalion
law,right,
Ic
Ap men
N IC PLICANT:If.atter making this Certificate of Esemprion.you should
N,
ub et to the Warkeri Compensation previsions of the labor CMe,you mug
.J O fa comply with such pmvisinm or the Permit that he seemed revoked. -
�� CONSTRUCTION LENDING AGENCY '
�-+ I hereby affirm that there i,a Construction lending agent'for the perfurmance of
�i> the work for which Nis permit is issued(So.309'1,Cl,C.)
0.Q lenders Name
z lenders Address
a.
O 0 I certify Nat 1 have rtaa at city and
and state Nat the above laws
10
U.!' amen.l agree a comply with all coy and county ordina"n and sum laws relating ro
0 rU' building construction,and hereby authotia,representatives of thiwity to enter upon the
W above-mentioned property for inspection putlacs.
gy (We)agree to save,indemnify and keep harmless the City of CupeninD agaiml
.y A Iiabilities.judgmenWcosts and espen=which may in my way seer"against said City
V in Unce (the RNtAND
APPLICANTtanding of this rmit.
WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURRE��yDE,TIONS.SfADS
lac
f Applic�ar
Re-roofs
i1""
aoHAZARDOUS MATERIALS DISCLOSURE
PAW Type of Roof
Willy the
tn forum buildings..Chanusoreorandte huudousmaterial
As dcrotl by the Cupertino Municipal Code.Chapter 9.12.and the Ha1N and Safety
Code,section 25537()7 All roofs shall be inspected prior to any roofing material being installed.
0Yes No
F
the applicant forum huilding occupant use enuipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mlt handous air conumitunu as deoued by the Bay Ams Air puably Management all new materials for inspection.
ID;ici?n'W `1
❑Yet 3ONu
I have read the bearrddnu.gracrish requirements undo,Chapter 6.95 of the Califon
ealth B SaftyCde,Sections 75505,25533 and 25534.1 Lha lydt,building
not Congo y Nve a unanl Nu it h my reaponsibllity m otify occupant of thelmer am ich mu mel p' umce of a Ocratficat4fOshwcy. Signature of Applicant Date
DS 2
Dr,Dthanvna. earl Date All roof coverings to be Class"B" or better
CITY OF CUPERTINO
TEMP POWER
IC OF
CUPEkTINO PERMIT APPLICATION FORM
APN# � ^ � '' Date:
Building Address/
/, -6 SL20 D/'G �j v2 . �[o�Ev7i"o , 4 �$v/�
Owner's Name: Phone#:
Contractor: j�� Phone: License #:
Gi?f-s
Contact: Phone: o d'-330 - i6io Cupertino Business License#:
Building Permit Info:
Elect
Job Description: �/ 1
Residential,a Commercial ❑
Cost of Project: C
Qty. if
A 1' le Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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