05050157 CITY OF CUPERTINO a rI.
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BUILDING DIVISION p$ j1' C0NTRACTOR TNPOWATIO
s�„ 3F
BUILDING ADDRESS: THANH HA CONSTRUCTION PERMIT N'05050157
OOSOSO1S7
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY O. C NIROL NO.
ARCHITECnENGiNEER: BUILDING PERMITINFO
E UMB MECH
+LOQ LICENSED CONTRACTOR'S DECLARATION lobDescri to
�+ 1 M h "no"Net I am limned under provisions of CMpter 9(cemmencog
with Section 70fA)af Dlvisian3ofthe Businea ad euians Code aM mylicense ie y
'o,�- kOnnClassderrecL g LK g - INSTALL TEMP POWER POLE 6/� - 0051
t5 Lleena Class
�6
Dan �g0ECmcO �I�®'�G
s I understood my plus Mall he used as publicblicm:nrN
soil Licensed Professional
3qy� OWNER-BUILDER DECLARATION
B E 1 homhy sRrtm
that I am exempt from the Conualofs License Law for to
Lf 0 following mason.(Section 7031.5,Bualmas ad Profesduns Cade:Any city of county
$ which requires•permit in construct.alter.Improve,demolish,or repair ay structure
'^ prior to its imuawo,also requires the applicant for such permit o file asigned statement
that he is licensed purwam to On prhAsions.fdoe Conuawrs license law(Chapter 9 Sq. Fl. Floor Area ValuatiO
6Ss (commencing with Sectit:00D0)of Division 3 ofthe Business and Professions Code)or
that M Is exempt Nemfrone sod the bub far the alleged tamption.Any violation of
nowt comate the Bove hundrreedlidalho 5500711 subjects the applicant o a civil penalty of 3 A'BIlI Vi)gr0 0 Occupancy Type
01,uownuofthepmpsy.wmyemployeeswhowgesu Nabsokeompe don,
will do the wark,ad Nemu arm is not intended oraQered fauak(Sec.7014,Business Required Inspections
sod Professions Cock:The Conhumr's License Law data trot apply m ns an owner of q p
property who buildsurimpavesthernon.and wMdouaschwork himself w Wough his
Own employee,provided that such improvements art not intended woRertd forage,IL
however,the building or Improvement Is aid within one yen of completion,the ownw-
Wilder Mil have the burden of proving dot be did rot build or improve for purpose of �
arc.).
❑1,an Owner of the property,an eaclusively,contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)TM Conlratwta Li- .
cense Law data not apply in an owner of property who Wilds or Improves therton,ad
who contracts for such projects with a contrscuer(O licensed persesm o the Conuactofr
License Law.
❑l am eampt under Sea .B&PC for Nis muon
Owner Data
W ORKPR'S COMPENSATION DECLARATION
1 hereby e01rm under penalty of perjury cox of the following declen0onr. -
1 haw and will maintain a Ceolfreste of Coaem ro self-imum for Wo k esCampen-
ation.as provided for by Section 3700 of the Labor Code,for Ne performance of Ne -
work for which Nis permit is issued.
❑1 have ad will maintain Worker's Compensation Insurance.u required by Section
37W of Ne Labor Code.for the performance of the work for which this permit is issued.
My Warkefe[ComLpemadon Inrynna Tw and Policy num r an:_ 0
Caller. )LQ' awry
G\ Poliry No.:
CERfIFlCATE OF E%EMPr10N FROM WORKETY
COMPENSATION INSURANCE
Club seNan read not W completed if Ne permit Is foronc hundred dollars($100)
or lea.)
1 ceolfy that In the performance of the work far which this permit is issued,I shell not
employ ay person in ay maser a as in becOmCabjecl m the Workcrs'Compena0on
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making Nb Ccniftnte of Eamnption,you should
become subject m the Worker's Compensation provisions of the Labor Code,you mat -
,Z foMwith comply with such previslou w this permit Nall be decreed mated.
zCONSTRUCTION LENDING AGENCY
Nw
F
I handiny.M.
Ne Vert issued(Secd 097,Cin{agency for the perfurmace of
CYi ti the duh for which this permit b Waned(Sec.J097,Civ.C.)
Q LeMer's Nunc
z larrdeh Address
V Q 1 coolly that I have need this application ad sou that the shove Infoura len is '
Is. caner 1&Van to comply with all city ad county ordinates and sou laws mladng in
C) building convection,ad hereby Maine representatives of Nis city to enter upon du
4 above-mentioned property,for inspection purposes.
(We)agree m ave.Indemnify ad keep harmless the City of Cupertino sgalwt
tirn liabilities,judgments,casts ad expenses which may in any way accrue against said City
V in consequence of the gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITHALL NON-POINT Issued by: Date
SOURCE VOULATIONS.
A or- Re-roofs
Signature of Applicanu'Cowratur Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building aceup o,stom or haMk huudous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health ad Safely
C Scci an W32(an All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Will the applicant or future building occupam use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haardnu air conominats u defined by the Bay Arta Air Quality Maugcment all new materials for inspection.
❑Yes ❑Na
1havemad Ne hamdousmaurialsmquimmenmunderChapterG95ofthcCalifor-
bHa1N&SafetyCede,Sectiuu25%5,25533ud25534.1u ram NmBthehuilding
oes not currently haw a ummL Nat it b my responsibility m notify the occupent of Ne
yulmmcnts which mum Wmelpdormivuace ars ecol0este of occupuuy. Signature of Applicant Date
�� dr °1��LgnAll roof coverings to be Class"B"or better
wner or authorized agent Dan
i
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aCOF Fax(408)777-3333
10UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT oS�S� (S
19961 ea.l- Ire- L cup e
OWNER'S NAME: YOALPHONE # q-o$—2-o — zS1
GENERAL CONTRACTORML
A FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 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
Of_,z —0200 '
Owner/)tontractor SignaKure Date
p,Lr6 of 54-
CITY OF CUPERTINO
TEMP POWER
� Of
CUPERTINO PERMIT APPLICATION FORM
APN# 316 - 3 /
Ibr3 _ 0 I I Date: c7S — 2 — 200
Building Address:
Owner's Name: Phone#:
�4, . log z°6-z,P/e
Contractor: T/\/ .G+ n/l/1 f'1/ 1 o Phone: V _6 66-888 License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect � "I�
Job Description: n� a CL, rre,� roaf -J,, it
r�
Nd an a�-t-�o�eo( a- U.�+f cid wv�+--t
ResidentialCommercial ❑
Cost of Project: /
(r
Qty. if
Applicable Fee lD Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING