01050166 CITYBUILDING DIVISION
INNPERMIT CONTRACTOR INFORMATION:.
OO
BUILDING...
f LO11]] +/—PORTAL AV PERMIT NO. 1050166
OWNER'S NAb111E: APPLICATION SUB DATE
CALIFORNIA WATER SERVIC CO 05/22/22001
HONE: SAND TARY NO. CONTROI.NO.
pp00 BUILDING PERMIT INFO ARCHIII:C'1'113NGINThR BLDG ELECT PLUMH MECH
ai� Gl r_I u CU
F y 3 hICI:NSEU CONTRAC'TOR'S DIiCLARA'I'IGN Job Description
OZ_ 1 hereby uRnn that I am licenseV under provisions of Chupter9(commencing
Fmt't9 wi�hSerioncan Division JafrheBusiness and P/orex' ns Ie a am` ELECT. PANEL AND RECEPTACLES.
q'y� is to full force an RL P_ Y
E <, License Cts,, a`f �.� Lia,p lV J
e�O a U U _ Cantructo'
u7 fin ' HITECT'S U'CL1 ,
or
g 1 nndetamanJ my plans shall W usrl a public records
dp Licensed Prom,snnni r \ ,•— -
OWNER-BUILDER DECLARATION I f
o I hereby action that I am exempt from the Comment's License
(:3Q billowingre. n,l&f n]BiI50v in findPr talo Corte:AnY af - {'
Sri Cx G which require, Ix t t r trt,alter.improve, lih p r arbor , i
a3� pr to lsissuance,also req thapplicantf such Permit rile gn le-c t
Nath T bene puma ll thepr i i n- fNeC ntmcmt Lan. La Sq. oor r Valuation
(c mneme hhSet nmoun fheh; nl fth B .' ssandP 1e. _
,.,Thai d e o exempt tlmrafmm n ul The h.eTs for Om t IIcgW oxo opo on.Any violation -
afSection]1tby anyapplicantforapermit mhjreTs the epplicam Toocivil penahy
,if or rare than
five handled sofas(INTO). APN Number Occupancy Type
01,as owner of the property or my employee with wages as their sole cmnlxnection, 316321058. 00
will Jo The stuck,and the uructure is nor intended ser offered Inc sale(Sec.70F4, Required Inspections
Business and Professions Cale:The Contractor's License Law does not apply a an q
owner of pperty Who builds or imprares therm,and who does such work himself 304 — ROUGH ELECTRICAL
oro
through his own employees.provided that such impmvemcros arc not intended or
of feted car sale.If,however,me huddi iig or improvemcat Is said within one year of 501. — F I NAI_ ELECTRICAL ENERGY
completion,the owner Wilder will have the burden of proving That he did oat build or
impmvefa inurpokeofsale). 505 — FINAL ELECTRICAL..
❑1,as owner of the Properly,unt exclusively contracting with licensed contractors to
construct the project(Sec.7144,Business and Prolessions Cale:)The ContramorN
License Law Jaz oat apply eh un owner of property who builds an imposes thereon.
and who earmark for each projects with a amara me)Iiecnaed pursuant to the
Cmanteamr's Licensc Low.
❑1 sent exempt under Sec. .B&P C for this moms
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby al Arm under penalty of perjury one v1 the following declarations:
40 ❑ I lacrimal will maintain a Cenilicate of Conran to self-meare for Worker's
Compcnsmion, as provided for by Section 3700 of the Lahor Code, for the
,commerce of the work for which this permit is issued.
❑1 have and will maintain Workers Contpenation Instance,as required by Section
3700 of the Labor Code,for the per nmmce of the work for which this permit is
issued.Myylgr C m nsu ....neccurtic)unJ .aS nu be re:_
My ,
e C/ Y 3 p J
Carrier. o p Policy No. 9 0
CERTIFIC.AATI'O'N OF EXEMPT10N FROM WORKERS'
COMPEIJSATIUN INSURANCE
flTis section need not W completed if the Permit is for one hundred dollars
($100)or less.)
1 century that in the la,norntmae of the work liter which This permit is ismeJ,I
shall not employ any person in any manner so a to become subject to the Workers'
Compensation Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
bomu
ece subject the Workers Compensation provisions of the Labor Cale,you must
Q 0 forthwith comply with such provisions or this pemhit shall be Deemed revoked.
ti
F CONSTRUCTION ruclimLENDINGlen AGENCY
tea ' thereby affirm ohm thereisa c..ad(Sic. lending agency fur Ne performance
of Lender's
stark for which This pemhit is issued(Sec.3047,Civ.C.) ,
I order's Name
Z Lender's Address '
C..7 1 minify Thai 1 have mad this application and sem that the neve instruction is
correct.1 agree ah comply with all city and county ordinances and state laws relating
[) To building con.sotrtion,and hereby authoom representatives of This city to enter upon
the eeve-mentioned property far inspection purposes.
CL. (We)agree to save.indemnify and kap harborless the City of Cupertino again '
City Iiabii ties 'wit ties.costs and expenses which may in any way accrue against said �''t� �r�1•-. J
V City in T equence of The ming or tM1is pemti \t Jr J DatO `� `•—� l
r City I .TUNDE S )$AND WILh C' PLY WITIf N.LN NPO Issued by:
ar raandcontwtor Q/� ate Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant nr future Wilding occupant sum or handle himardous na ial Type of Roof
as defined by the Consent.Municipal Codes Chapter 9.12,and the Health and St
Cale,Section 25532(x)?
❑Yrs 0N All roofs shall be inspected prior.to any roofing material being installed.
Will the upplicamar fumm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hamrdoos aire'onccommo s as defined by The Bay Area Air Quality Management
atria, all new materials for inspection. Applicant understands and will comply with
ora ElNo all non- oint source regulations.
1 have read the Wo Nous materials requirements under Chapter 6.95 of the
California Th&Soddy Code,Sections 25505,25533 and 25531 I understand]but
offichui Jswsnntcuce flyhuvcu mnnn6tbaThly my rexpansibility Innotifythe
vecupan The reyui which most be i prior to issuance of a arficateof
Occup' y Signature of Applicant Date
r nr aateriva agent ata All roof coverings to be Class `B" or better
OFFICE