04010088 CITY OF CUPERTINO
i BUILDING DIVISION PERMIT XONTRACT R INFORtMATION .
. ,
BUILDING ADDRESS: CCK CONSTRUCTION INC PERMITND04010088
OWNER'SNAME: [ PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL 10.
4
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG, ELECT PLUMB MECH
=7 0
o o LICENSED CONTRACTOR'S DECLARATION
U 1 hereby affirm that I am Iiconu0 under provisions of Chapter 9(commencing - Job Description
Dly
withSectionCo.n]d.fifeDivision3ofd,c Ausinem and Professions Cole,and my license is
I.rmlf, and nfrt"' TEMP POWER POLE
Ll Z License Class Lk.a
&f,p Data Contractor
i q ARCHITECTS DECLARATION
Y a 1 understand my plans shall he used as public records
Za,—0 Licensed Professional
OatNER-BUILDER DECLARATION
0 f I hereby,(firm on 1 ore exempt from the Convaemr'a License Law co the
p O following moon.(encu,,](131.5,Business and improve,
de io li h.or:Any tiny or county
which requires a o,also re cores the alms impmvu,demolish,or repair any structure -
y
poor it)its issuance.also requires the applicant for such permiuO file asigned statement
�a that he is licensed pursuant In the previsions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Business and Profession&Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant m a civil penalty of 3 4APAl6`UI®T�erO 0 Occupancy
not more lean five hundred dollars(S500). p y-Type
❑I,as owner or the proporly,or my employees with wages as their sole compensation,
will do the work.and Ne structure is not intended or offered for ale(Sec.7044,Business
and Professional Code:The Contractor's License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who doesauch work himself or through his
own employees,provided than such improvements are not intended proffered for sale.If.
however,the building or improvement is sold within can year of completion.Ne Owner.
builder will have the burden of proving that he did not Wild or improve for pappose of -
le.).
1,as Owner of Ne property,am exclusively convecting with licensed contractors to
co el the project(See.71X4,Business and Professions Code:)no Convactar's Li-
on
i- .
came Law docs not apply to an owner of property who builds or improves thereon,and -
who contracts for such projects with a c,ntracnor(s)licensed pursuant to lite Contractor's
License law.
❑lam axe a ,B&P If Nis mon
Own r Da e
'S COMPENSA NDECLARATION '
hereby from under pemlty o(perju fie of the following declarations:
1 have and will maintain a Cenifcam of Continua self-Imam forworkers Compon-
station,as provided for by Seetion 3700 or the labor Code,for the performance of the
work for which Nis permit is issued.
I have and will maintain Worker's Compensation Insurance,an required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Wefxers Compensation Insurance earner and Policy number am: _
Carver: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
-COMPENSATION INSURANCE
(This section need nol he completed if the rynmll is for one hundred dollar 15I W)
or less)
1 certify Nal in the performance of the work for which this Permit is iniad,1 shall not
employ any person in any manner u as to become subject o IW Worked Compensation
Laws Of Califomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cordilleras of Exemption,you should
become subject in the Worker's Compensation provisions of Ne Labor Code,you mus
.JO forthwith comply with such provisions or this permit shall W deemed revoked.
nzt t--t CONSTRUCTION LENDING AGENCY
H 14 I hereby affirm that there is a construction binding agency for the performance of
C4 tom„ the work for which this Permit is issued(Sec.3W7,Civ.C.)
WQ Landers Name
z Lender's Add..
U Q I certify that 1 have read Nis application and auto that the above information is
Iy Conan.I agree to comply with all City and county ordinances and state laws relating to ,
Q C.7 building cordractlon,and hereby allfOriM reprise tatiM of this city to enter upon dm
>1a above-mentioned d propc costs
for impenies purposes
(we)agree to save,indemnify and keep hartnlem the City of Cupertino against
rFsDrIZ in consequence
cosuang expenses which may in any wayacemc against mid City
(„),'� A consequence of the UNDERSTAND
granting of this permit.
^t APPLICANT UNDERSTAND ILL COMPLY WITH ALL NO -POINT . Issned by: Date
SOURCE REG 1
Re-roofs
$' n0 C Cf IC HAM
ooloo a1C
ZARDOUSA ERIALSDISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hazardous mmerial
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
Ideas
Jc,Section 25532(,)? ......JJJJ��// All roofs shall be inspected prior to any roofing material being installed.
YmNo
Will nits applicant or future building arupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants ss defined by the Bay Area Air Quality Management all new materials for inspection.
`�❑Yes 3DNo
1have mad Ne WraWousmamrialsmquimmenuunderChdpmr6.95 oftheCalifr-
Hcalth&SafetyCOk,Seedons25505,25533 m125534.lundemwdthwiflW Wilding
not currently have a mnent,that it is my responsibility to nmfy the anoderm of Ne
uirements which m met 'ssuance of a Cenlfimm of Occup an y. Signature of Applicant Date
Owner. , ria. , I D,m All roof coverings to be Class"B"or better -
CITY OF CUPERTINO
1 TEMP POWER
UPEI�TIN� PERMIT APPLICATION FORM
( �� r rI
APN# CA
Buildin Address:
Io.S$V- 10§�o SANTA CIA
Owner's Name: P
rJ is L. � (W:496-231
Contractor: Phone: License#:
Ce1K (409)(063- 664-9
Contact: Phone: Cupertino Business License#:
Pk-0 Lt �� ► C s 6a�- 3g i b
Building Permit Info:
Ele ❑
Job Description: W �I�]sTe2�CT W-)
Residential Commercial ❑
Cost of Project:
•
Qt . 'f
l `ble Fee ID Fee Descrition Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
--`BUSLIC Business License BUILDING
z� 272 .
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