05050013 CITY OF CUPERTINO ,...r�a :r5�s's
BUILDING DIVISION PERMIT IAC-0 TAXOTORINFoI2NIATI.O,
BUILDING ADDRESS: CUPERTINO CONSTRUCTION INC PERMITN005050013
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY Wo. CNTROL NO.
RCHITEC rENGINEER: BUILDING PERMITINFO
BIRO EO PLQ MECH
O
o o LICENSED CONTRACTOR'S DECLARATION Job DeS l
(uj I ion 7 afRnn Nn I am fLh.Bu under rel Pontns of Chapter 9(commencing _ RNA
�
n withlllmlo ndafef Dlvldon3of the evainw and Professions Code.and mylicerrsek [/�Ifh\l
z in ucenlmuC�laAnd
d`Ree B Lm R L�'��7 � asm TEMP POWER
¢- Amar 2005
OECLARATI N
1 undersand my planuhall he used u public¢cords
3
t� Limned Army ami (�(� O ®�[� A
4r. OWNER-BUILDER DECLARATION {Fi�� �Y]Y,AI
I hemhy sloe¢this I I.S.exempt from Ne Conlncmfa c;A n c law for IM
D fallowing mason.Permit
7117LBusiness and Pmfeuiunsh,or Any m or county
"Z� which us issuance.
a promo re chef 4 alms,Improvemfor such
demolish,or e psis any mamuro
prior w
<
that he(commencing
Ilmosed eBushm animnxlaw(Chapmr9 Sq.Ft.Floor Area Valuation
zC� that M Is exempt therefrom
and gas
Division r th 0 al eged cram t Profon.AnyonACdan of
a$ ihe0 he b exempt Nemfmm and Ne buil far Ex alleged tumptlon.Any violation of rAvnP-wg,,.,..1,
Section 7071.5 by any Applicant for a permi0,ubjecu the applicant to a civil penalty of 3 Twin q ter0 0 Occupancy Type
not mom than five hundred dollen($500).
0 1,u owner of the property,ormy cmploycn with"Ina ureir sole enmpCrandon,
wllldotheworkmdtheammumnknotintorakdorolfemdforaak(Se.J .Businw Required Inspections
and Professions,Code: e Ommo me,Unions LAW owner does MI apply to m of e q ns P
property who bell&sur Ito prow thereon,aM who dees,uc h work himself or Nmugb his
awn employees,provided thatsueh Improvements are not Intended oroQered forsola,if.
however.Ne building or improvement is Bald within one you of Compledon.the owner.
builder will have the burden of pmving Net he did not build or Improve for purpose of
Asia,),
0 I.as owner of the property,am exclusively contracting with licensed contractors so
construct the pmject(Sec.7010,Business And profauions Code:)The Contractor's LI-
roue Law docs not apply to an owner of property who hu rob,or improve,themon.and,
who cornea for such projeeu with a conuumr(O licensed pursuant to the Conu,mofa -
License LAW,
0 l Am exempl under See ,B&PC for this reason
1037'00
ner Dam
WORKER'S COMPENSATION DECLARATION - -
1 hereby Arms under penalty of perjury one of dm following declandom:
1 haw and will maintain a Cerdfiosto of Consent to self-insure for WorkefsCompcn-
der.u provided for by Sardon 7700 of the Labor Code,for the performance of Bre
rk for which this permit is issued.
1 haw:and will maintain Workees Compensation Imur sum,As required by Section
of the labor Code,for the performance of toe work furwhich this permit is hutted.
y Workces Compenation Insurance carrier sed Polity�nsumber are:
rrier.�'✓•GhL C�.a+�p Policy No.7r 1v`j�-'OOZS
CERTIFICATE XEXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This section need not aecumplemd If the permit Y forouehumboul dollars(SIM) '
m lou.)
I Crofy Nm in Lou performance of the work for which Nis permit u issued.I,hall not
employ any person in my mmnerm as to become subject to tiro Warkera'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenlnate or Exemption,you should
become subject to the Worm's Compensation provisions of the Latour Code,you most
.J O forthwith comply with such pmvisimu or this permit Mall he demand invoked.
z tiF-r CONSTRUCTION LENDING AGENCY 1 hereby drum that thers k a Construction lending agency forty<performance of
a the wu k for which this permit is issued(Sec.3097,Ch,.C.)
WM Q Lender's Name
Z)z Lender's Add.
U Q 1 certify that I have read this application and atom that the show information i,
IT, !' comet.1 agree 0 comply with all city and county ordinances and ante laws rtkling to
O rV' building consuuedon,and hereby authorize representatives of this city m enter upon Ne
W shove-mentioned Property rw inspenian iurpmea.
6, (W))agree vo now.indemnify and keep harmless the City of Cupertino against
IzA liabilities.judgments.ensu and espuuu which may in my way acerae Against Said City'
in conequence of the
of
APPLICANT UNDERSTANDS ArND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature o(ApplicmUCoO m Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will theW
Cupnlof(alum ce
building ort
t am handle Health
omamdal
u dennM by tiro Cupno Municipal CMM ar
A.Chapter 9.11.ae Hulth roti Safety
Ask,Section 35531()7 All roofs shall be inspected prior to any roofing material being installed.
0Yes No
Will the applicant or future building occupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haarEnus air contaminants As defined by the Bay Area Air Quality Mamgement all new materials for inspection.
-
0Yca KNu
I hew mad the hvardrmsm umals requirements under Clupterd.95 orthe Carron.
nkHoalthk Sakty Codc,Swd=25505,25533md25534,ito wmodthatifthe building
Jou rot cursemly how•mnm0,that It Is my ompmonsility m notify dm occupml of the
myuimmenu which must M met poortoissu arAc)rtincam orOccup Signature of Applicant Date
o.
Owner or ed.)rel nam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
i' Telephone(408)777-3228
C D Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
( o -,-,29- Saw Lam" , ® SOSoo/ 3
OWNER'S NAME: .at. x I.- PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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
Owner/Contractor Signature Date
CITY OF CUPERTINO U S z,S— o
� '' TEMP POWER
�CUPEC iNo PERMIT APPLICATION FORM
APN# Ox- — DCS Date: �- 2 -01�
Building Address: o r,9 g A-9
Owner's Name: A a �wti�� L Phone #:
Contractor: hone: License#:
lu. Cbi .�rw.�� i.(,.,lr- 2s3- grns� '7'��69�
Contact: 1 Phone: /� j Cupertino Business License #:
P�� C
Building Permit Info:
Elect ❑
Job Description:
Residential P) Commercial ❑
Cost of Project: �^
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE 'Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
2 � s3 �
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