05060028CITY OF CUPERTINOx
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BUILDING DIVISION PERMIT
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BU ILDING ADDRESS:
PERMIT 005060028
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY N0. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I thereby aRsrm shut I am limumd under provisions of Chapter 9 (Cm mencin{
p
with Section 7") of Division 3 bruise Busirw.• arel protections Code. and my licwe is
mfull rt effect.effect.c.
ceaa
TEMP POWER POLE
LicenseCou IJN
Dam Common,
ARCHrrECTS DECLARATION
1 understand my plans shall be used as public ran mma
Licensed Profusion.(
OWNER -BUILDER DECLARATION
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I hereby ofnrm that I em exempt from the Commuter License Law for the
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following much. (Section 7031.3. Business and Profession Code: Any city or county
which requires a permit to commons. alter, improve. demolish, or mp.ir any strucwm
prior to its issuance, also requires the applicant far such permit to rile asigned Comment
th lki,liccnudpuaanantwthepmvisiomefthe Contrsewr',UJ nwlaw(Chapwr9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cale) or
that he Is eaemps memfmm and me bub for the alleged exemption. Any vioudon of
3 4421TH fd®er0 0
Occupancy Type
Section yen a none applicant fora permit subjects the applmant m a civil penalty of
not
the pro pertylmmyemplendes wimwages uthehml. eampemmass
Required Inspections
evook. y
will do Newark,Cde:Tshe h
dointended araRe an
actapplterior ombws
cam,ed
and Code: The Cbnuamor's 0
Commode law dote not apply li an owner
q p
whions
property who his
enywho Wild, and is
l,Impr hended work homeliermetered
own employees, provided mot such for
own provided Improvementart not Intended m
an
nt is mid wit lemm, maoso.
however, me Wilding or improvement b sold aM yes of completion, the owned
a did
builder will have tite WNcn of proving ren W did not Wild m Improve for purpose of
Cam.).
❑ 1, as owner of the property, am exclusively commaing wilt licensed conuactoo to
construct the pmjeo (see 7W, Business and Profnstiuns code:) The Common. U.
cane law dose not apply m an owner of property who Wilds or improves themon, and
who contracts for such projects with a contramor(s) limned pursuant m the Contractor'.
License Law.
Ioma pt under Sec. B&PCfcpmi mason
Owner Dan,
WORKER'S CO P TION DECLARATION
I hereby ell. under, penalty o Cry one of the following declandom:
I ham and will maimen a Certificate of Consent m self4mu a for Workees Compere
satlon. as provided for by section 37011 of the labor Code, for the performance of the
wok for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the labor Code. for the performance of the wort for which this permit is Issued.
'
My Worker's Compensation Insurance cattier and Policy number am:
Cartier, Policy No.: _
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not W completed lime permit isfbronchundreddollara ($100)
unless.)
,
I certify mat in the performance of the work for which this Permit b issued, I ahall not
employ any perron in my man cr cpmc object to the Worker'Compensation
-
LawsofCalifornin Dae -
Applicent S(h !n
NOTICE TO APPLICANT, Ir, after making this CehiRcate of Exemption, you mould
become subject to the Wwkces Compensation provisions of the Lada Code. you most
forthwith comply with such provisions to this permh shall W deemed tcvoked.
CONSTRUCTION LENDING AGENCY
I to mby affirm that Vert is. coestem9nn funding agency for the performance of
the work for which this permit is issued (Sm. 3097, Co. C.)
Lendcts Name
,
Lender's Address
I certify that I have mad this application and mm that the above Information b
Coma I agme to comply with all city and county ordinerms and sote laws misting to
Wilding construction. and hereby authorize representatives of this city m ever upon me
ahmm-mcommed property for inspection purposes.
(We) agree to ore. indemnify and keep handless the City of Cupertino against
liabilities, judgments, costs and expense, which may In any my acrnm against said Coy
in consequence of the granting of this permit.
APP ICA UNDERSTA ND WILL COMPLY WITH ALL NOWPOINT
Issued by: Date
SO UL 770N5.
6
Re -roofs
Type Of Roof
Si ueof ApplieurrX nusetm Date
HAZARDOUS A ALS DISCLOSURE
Will me applieamwfuwre it i occupanutoroorhandlchaardousmaterial
,
ns dcOncd by the Cupedino Municipal ode, Chapter 9AL and de Hcalthand Salcty
\\
calc. Semon 25532(.)7
[3 Y. i_
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment or devices which
.mit ha)ardnm air coasormanu u dclined by the Bay Area Air Quality Managomem
all new materials for inspection.
Di u ct7
❑Yu t/p�Ip/n
1 have mad the hunmwa macruisrequimmenst underChupwr6.95 elite Califor.
nb Halm&Safely Code.Scmats25505.25333and25534.iundemm�dmulfine Wilding
does not Prettily have a W ... 4 thikit is my mapmehility to nodl'y the occupant or the
mq ntswhieh tWmet owl aura na,mofocea ey.
'
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
or agent ,m
&CITY
�UPERTINO
Community Development
10300 Tom Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
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to
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
I am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the following information
Date
Owner/ Contractor Signature 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
Owner/ Contractor Signature Date
i
1 0, av, - -
SCITY OF
CUPEkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
66 a
APN #
�l 00, 00
Temporary Power
Date:
Building ®dres�
Elect. Permit Issuance
Owner's Name:
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BUSLIC
Phone #:
. yo X219-83(o
Contractor:(� Phone:
1J
License #:
Contact: Phone:
Cupertino Business License #:
Building Permit Info: U fp-� �rYn �'p2� ��
Elect 2k'
v�pGv E O LE,
Job Description: j
Residential �Q Commercial ❑
Cost of Project: 8 O O. z
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Qty. if
ADDlicable Fee ID
Fee DescriDtion
Fee Grout)
BTEMP
Temporary Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
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