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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
NICE & RIGHT CONSTRUCTION
O 05040169
MMM07
PERMIT ISSUE DATE
TRACT IICTT
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SANITARY OL 140,
ARCHITECTAINOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am Remsed under prevision, of Chapter 9 (commencing
P
with Section 7000) of Division 3 of No Business and Professions Corin, end my license is
in full forte and effect a (721 It
License Class _Q_ Lm# l7 f'7
TEMP POWER
Dem f•_IL Contrmror M�,Zafl GU"T
T'-�ll DECLARATION
1 understand my plans shall he used u public records
V 4--,-
Licensed Profusion.I
OWNER -BUILDER DECLARATION
1 hereby .farm that 11. axempe from Ne CnmranCo License Law for the
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Maso andsee,dProfession Cade: Any cin or county
following muon. (Stolon 7t17
str t. aloes.
which requires permit m construct. Improve, demolish, or pair any anunuro
e
intern) its mused p. Alm rrquiru the applicant fofsuch permit m rile, ChApt rel
a ppli
m. (C
he Ancingwit Pucc1bm7 lhepmviainnenof
Sq. Ft. Floor Area
V81Ua110
sines Corin) tar
Division 3 of exe end Profession Code)
(commBusinessland
(commencing with Secdrom
al egad on, A
that he is exempt therefrom and Ne buts for Nn alleged exemption, Any violation of
and the
3 3�' YENI91tef 0 0e
7YP
Section 7031.5 by any applicant for a permit subjects the Applicant m a civil penalty ofOccupancy
not more than Ew hundred doau, (5500).
❑ 1, u owner of the property, m my employm with wagon u their sole compensation,
Required Inspections
willdo tie work, and the structure ism, intended mattered forsats(See. 7014. Business
and professions Cade: The Con error's License Law time ant apply m an owner of
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property who bis Ilds or improveuhercon. and who doe s s nth wort himself or through his
own employees, provided that such Improvements am not Intended mnaertd forsale. If.
however. Ne building or improvement Is sold within one year of completion. the owror-
builder will have the burden of proving that he did nm bold or Improve fee purpose of
sale.).
t7 1, as Owner of the Property, am exclusively contracting with Ilceueti comrserom m
conumeCthe project (Sac. 7044. Boatman and Profession, Code:) the Conlnprors L4
mese law does not apply to an owner of propeny who builds or Improve, Demon, and
who contracts for such projects with a commetar(0 licensed pursuant an de Canoacloes
License Law.
❑ 1 em enempt under See. . B & P C for ibis mum
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby afar¢ under penalty of perjury am Often following declarations:
I haveand will maintain aCertlficateof Consent roself-M... fm WOrkera Compen-
'
Ilan, an pmvlded for by Section 3700 of the labor Code, for the penmmonm of the
work for which this Permit Is issued.
❑ 1 have and will maintain Worker's Compensation Inaurecm. As required by Section
37ODof Ne Labor Cade• for the performance of tie work fee which this permit is Issued.
My Workers Compensation Inm ance carrier and Policy number Am:
Cartier. S%A%� LI�VI% Policy No.:t2axogil-w
CERTIFI ATEOF&EMP ION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thin section need not heeompleted if the Permit Is foram hundred Mllan ($100)
or Inss.)
1 cenify that in the performance of the work for which this permit Is issued. I shall not
employ any Perron in any manner an As in become subject in the Workers' Compensallm
Lawn of California. Dane
Applicant
NOTICE TO APPLICANT: If. after making this Cenifecam of Exemption, you should
lexurne.ubjmt in tie Worker', Compeneenm provl.inna of the labor Cods. yon must
forthwith comply with such provisiom or this permit shall be coma revoked.
CONSTRUCTION LENDING AGENCY
1 hereby splum Nn Nem its construction lending agency for O n Performance of
Ne work fm which Nb permit is issued (Sec. 71191, Civ. C.)
Leaders Name
Lender's Address
I «eify that I Mw road this application and Nu tons Ne abort Information la
correct. I agree in comply with all city and county aNinana and sue laws mining in
building ctmsuue0on, and hereby outhodsa representatives of this City to enter upon tit
atmve-mentioned property for inspection purposes.
(We) agree to save, indemnify and jeep homeless the City of Cupertino against
IiabilWes.judgmenla.costs and extenuator which may in any way acme against sold City
in consequence fthe granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE R TIONS. r-
T
Re -roofs
Signatmnaf IimnUComracmr Date
HAZARDOUS M IAIS DISCLOSURE
Type of Roof
Will the appilcant or future ing occupant stem An handle huandms material
u defined by the Cupertino Mun icipal Code. CTapur 9.17. and the Health and Safety
ode, Scod eAus37(.)9
All be inspected to any roofing material being installed.
❑Yoe �No
roofs shall prior
I
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant m furore bulldiOg Occupant sac equipment m devices which
emit hanrdnus air contaminants As defirod by the Bay Arm Air Quality Management
all new materials for inspection.
District?
0 y R No
Chapterd.93ofthe Calif¢-
ihe. mad! the h,Sft'd
N&Safoy Coda 25505, 353requ3ro nsN,icr
It my resu1735)/.l WMollM"irfte=op =opanj
Jou col commonly haw a tenant. Nat II u my responsibility u notify Ik ocoupant of the
does A temanna most l
requircmcmav'ehmuuAemmpnorwissuenceofACcnifeaeo(Occupancy '
Sign Applicant Date
U&�-z 4x—
All r coverings to be Class "B" or better
Owner riflWorisul agent Dau
f
JOB ADDRES
OWNER'S NAME:
GENERAL CONTI
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
PERMIT # i
I am not using any subcontractors: _ v�
Signature Daite
Please check applicable subcontractors and complete the followine information:
r/Contractor Sign
Date
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
r/Contractor Sign
Date
CITY OF CUPERTINO q
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TEMP POWER vS�
PERMIT APPLICATION FORM
APN #
Date:
Building Address:
1
�
Owner's Name:
Phone #_ 60-d
Contractor: _
Phon
t�1
License #: �Z /
'CAIS
Contact:
Phone:
Cupertino Business License #:
Building Perri -At Info:
Elect
Job De cnption:
Residential N
Commercial ❑
Cost of Project:
vo
In
u
Qty. if
Aonlicable Fee ID
Fee Description
Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE 'Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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