04030158 CITY OF CUPERTINO aa^^ss �a��'r��a�.. e��"rr -`" (gam)'` h 2 111-1 y��
BUILDING DIVISION PERMIT VQI�'.,rJ k T 11Vk`l R�r ION.,
BUaorvanoDRFss: NICE & RIGHT CONSTRUCTION COMITNo.04030158 '
•OWNER'S NAME: PERMIT ISSUE DATE
BEN LEE irr 7.Tjr-Ajyj2TjT5� DR
ONE: SANITARY Ni.3 O OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION IOb Description
F 1 W.by affirm Nal l am liamed under provisions or Chapter 9(commencing
n� wW Section 7is(11).(Division 3 of the Business and Professions Code,and my license is
in
infullforceandclfecl. ffff �2/ 4Sfs' TEMP POWER POLE I
E0
ZY1 'a
License Chao
o L5 Lk.d ■ �AL
:1Dem la/]/n/-� Contractor N Q
/C� D I Ci FIT i`'II`1,V
w ARCHITECT'S DECLARATION
�i i understand my plans all M used as public mccrdn
Licensed Professional
MAR 1 $ 2004
OWNER-BUILDER DECLARATION
1 hereby.. affirm m 11. exempt Item Ne Contractor's Co License Law for the a�
$9 which
mama.(Smdon](131A Business and pr vs,de Professions Carr:Any s y or aunty BUILDING
which mquircs a permst re cores un aIle.hnprow,demolish,nr c a s if any timelum
Fi'yn that he itsissuence.ats0 requires lhevisiosoffor Me Contormitbfleon LawJ statement
f 0lhatheis encinnsedPurstion7"epmvivisionofthenusinestndPoofLaw(Cotnoteode)or Sq.Ft.Floor Area Valuatioff
that he Is angwiNStttioin and f basis for
Maleged exe endon.Aninvi Cate)of
., Net he is exempt Nemlrom and dee beats far Ne alleged exemption.Any violation of
Sect)m 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty Of 3 MI$Millibeir0 0 Occupancy Type
not mom Nan five hundred dollars(5500). _
❑I,as owner of Ne property,ormy employers with wage as theirsole compensation,
will Pr Ne work and e: awctum ismnes Lndede Law does
n t apply
in an Boniness
and Pmfwh ons Cade:The Cdntremen,License law data not apply lf an owner of Required Inspections
Own cro wices,provided
that such Imp(andwho doessuch wnfkh(maelred through his
own employee,provided that such improvements arc not intended MPlemnd for Owner.
huilder ,the building or improvement is sold di inane yam of completion,me Owner.
builder will have Ne burden of proving Nat he did not build or improve for purpose of
sale.).
❑1,as owner of the property.am exclusively contracting with licensed camrecmrs to
convect the project(Sec.7046,Business and pnsfessidns Cotler)The Commmr's U.
come Law doe not apply to an owner of property who builds or improves thereon,and
who convects for such projects wide a conummr(s)licensed pursued,to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this mason
2MMERam 31f7 to
Owner WORKER'S CC IPENSATION DEOZLARAION
1 hereby affirm underpenalty of perjury one Of Ne following declaratimu:
I have and will maintain aCeNficale ofConsenl to self-insure for Workers Compen-
7307'
ion,as provided far by Section 37M of Ne labor Cade,for the Performance of me
rk for which this permit is issued.
FI I have and will maintain Workers Compensation Insurance,as required by Section
00 of the Ube,Code.for the performance of Ne work far which Nin permit is issued.
y Workers compensationInsurance carrier and Policy number am:sprrier: C��"'/f--_NPoliey No.: Oa 1291 /—o 3
CERTIFICATE OF EKEMPI30N FROM WORKERS'
COMPENSATION INSURANCE
(Thts section need nathecomplemd if the parent,is forone hundred dollars(11100)
or less.)
1 certify Nal in the performance of me work for which this prfmit is issued.I thall not
employ any person in any mannerm an m become subject to Ne Worlans Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL sutler making this Cenifcate of Exemption,you should
become subject m me Worker's Comp.nsadion provisions of me Labor Code,you must
O O formwim comply with such provisions or this permil Nall br deemed mvoked.
ti y CONSTRUCTION LENDING AGENCY -
'r-i IMmb,.M.that More in ac.nswnian larsingagenry for Me perform do,.f
[(,7 the work for which Nis permit is issued(Sec.3M,Civ.C.)
aQ Lender's Nam.
=z Landers Address
U Q 1 certify Nat I have red this application and sure that the above Information is
Igy correct.1 agree to comply with all city and county ordinances and stsh laws minding In
0 U building construction,and hereby auNorire mpreasn4lives o(miscity to enter upon the
>a above-menlioncd property for inspection purposes.
(We)agree to save,indemnify and keep harmlcsn the City of Cupermm against
nFi N Ilabilifes,judgments,casts and expenses which may In any way secret against said City
U 7 inconsequence of me gmnling of this Permit.
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE LATION_S.
4 3//?Id If Re-roofs
Sig(t!rc�af pplicmVContrmtor Dao
HAZARDOUS MA IS DISCLOSURE Type of Roof
Will the applicarn or future building Occupant store or handle hma muss material
as defned by the Cupertino Municipal Code,Chapter 9.13,and the Hcalde and Safely
Id.
ade.section 35532W)? - All roofs shall be inspected prior to any roofing material being installed.
C]Yen No
Will the applicant or wm building Oecupam use equipment dr devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haeardous air contaminants n defined by the Bay Amu Air Quality Management all new materials for Inspection.
istrict?
❑Yes '-QI No
I have mad the to srNms�materials mquimmcnts underChaphr6.95 dime Califon
is Health&Safety Cod.,Sections 25505,35533 M115534.1 mulerund the if tlw Wilding
nor oily haw a mens,Nal it is my msponibilitym notify d¢occupant of Nc
galm ants hi mllsl M e (lar m InaanCC 0f CCnifiCdN df C.CapNry.
�°. f Signature of Applicant Date
.verse( rauthoriudagcm Dam All roof coverings to be Class"B"or better
CITY OF CUPERTINO
TEMPPOWER
CUPERTINO PERMIT APPLICATION FORM
Building Address: /
Owner's Name: P n #:
Contractor: Phone: n License
IC. ",,(S e o l d —� 174cS&
Contact: Phone: C eifinoBusin�s License#:
— (� — O 2
Building Pe it Info:._
Elect
Job Description:
Residential Commercial ❑
Cost of Project: �o
D .
•
Qt . �f
lic ble Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
•