04040093 a CITY OF CUPEwrINO / .+.--t*ta� "-
BUILDING DIVISION PERMIT ICONTRAGORTORriINFORMATION�
B.DING ADDRESS: PERMIT NOO 4 0 4 0 0 9 3
10077 SCENIC BLVD
OWNER'S NAME: PERMIT ISSUE DATE
STUART WU 2004
NE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o 0 0
.Op LICENSED GONnseda,OR'$DECLARATION
a 1 hereby affirm that 1 is.licensed Ba an Of Chapter 9(commencing Job Description
n< withllf. Bot Division Jof the Basin and Rufessiuns Codc.anJ mylicense is
-nn infullf err 73 j�C�� TEMP POWER (FIRE LOSS)
DLl? LicenseC p
s Ln.
Da Contractor CONTRACTOR: AAA PLUS CONST. f!/
¢< ARCHITECTS OECL T N
2 unit
Hans ahyNcde li Rods �� LDieu '
Is.
Livx rofcssianel
3
OWNER-BUILDER DECLARATION >e
.�<Z I hereby affirm o that 1 1. exempt from me Cssions o Liccnu Lew for the
❑o following mason.(Section]1131.5,Business and Professions Code:Any oily or county
e m which requires a permit to uirm;the
eller,improve.demolish,m e a sig ed structure
'ray that h n its caned e,a tmo t 1.the hprovisions nt of
such Contractor's
to Eense,Law(Chastatement
x < (CommencingWithSection7(Xk)ofvsion3 he Comsiness ndProflaw(Chopmr9 Sq. Ft. Floor Arca Valuatio$600
mF o (cat he is(CommencingWith Section sung of Division r the
al aged Business and Professions Code)on ser
y root io is exempt memfmm end me bats for the alleged exemption.Any l tally of
Section than
five
any red delfor a ta,,
(S50 rmll objects the applicant to a civil pcnahy of AIDN Number Occupancy Type
oat mote than fiw hundmd dollars(5300). P Y YP
❑I,a owner of the prolixity,or my employees with wages as their ole compensation, 355709002 . 00
will do the work.and the nmmum is not mended or offered for sale(Sea]Baa,Business
and Professions code:The Conmators License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who docs such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,me building or improvement is sold within one Inter of completion,the owner-
builder will have the burden of paving mal he did not build or improve for purpose of
sale.).
0 h as owner of the property,am exclusively contacting with licensed extractors to
consumer the Project(Sec.]Baa.Business and Professions Code:)The Com amor's Li. .
cense law does not apply to an owner of property who builds or improves themon,and,
who contracts for such projects with a contractor(s)licensed pursuant o the Contreaot's
Liccnu Law.
O tem exempt under See. ,B&P C fee his reason
Owner Date -
WORKER'S COMPENSATION DECLARATION -'
1 hereby atrium under penalty of perjury one of The following dalanrions:
1 have and will maintain a Certificate of Consent to self-insure for Worker'sCompen-
sation,as provided for by Section 3700 of the Labor Code,far the armarance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,or required by Section
3700 ofthc labor Cod for the pmformance ofdh worifnr whiahmis pearcolissued.
M Workers o e ationlMnceca 'rand Polieyntrin ora
anicr. �olic0.: IT/f��5-ei }'d3
CERTIFI ATEOF (EMPI}(]If FROM WORKERS'
COMPENSATION SURANCE .
(This section need nal M complcteJ Ir the permir is foronc hundred dolhrs(;IIX))
nr Icss.l
1 cenify thio in the perro mance of the work for which this permit is issued.1 shall not
employ any person in any manner an a a,become subject to the Workers'Compensation
Laws of Callfomia.Dale
Applicant
NOTICE TO APPLICANT:IL after making this Cenilicate of Exemption,you should
become Subject to the Worker's Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall he deemed mvnked.
,z_t '-' CONSTRUCTION LENDING AGENCY
F+ t�+ I hcmhy ofOrm that there is a construction lending agency lot he Performance of
�i 7 the work for which this Permit is issued(See.711107,Civ.C.)
W a Lenders Name
z Lenders Address
U Q I cenify Onto 1 have read this application and sum that the above information is
Lf. F correct.1 agree to comply with all city and county ordinances and state laws rotating to *Date C C./ building conswction,and hereby authorim representatives of this city to enter upon the�-'a abovcmentioned property for inspection purposes.(We)agme to save,indemnify and keep humless the City of Cupeninp against(n liabilities,judgments,costs and expenses which may in anyway accrue against mid City
UZ in consequence of the granting of this Permit.
APPLICANT UNDER T NDS AND WILL COMPLY ITN ALL NON-POINT Issued by:
SOU EREGULA
Re-roofs
Si plicanUContracror Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or rulum building Occupant store or handle hazardous material
dcOncd toy the Cupeninn Municipal Code.Chapter 9.11,and the Health and Safety
We,semina zsslz(a)] All roofs shall be inspected prior to an roofing material being
❑Yes P P Y g g installed.
Will the applicant orrulombuilding Occupant use equipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
,it nazamnps air contnmmanH a Incl by the Bay Arca Air Quality Management all new materials for inspection.
bol
❑Yes Nn
1 haw moa the haallousmamrials mquimmcnu under Chapter 6.95 of me Cali for
itis Hcahh&Safety Cone,Seemn.]5505,1553Jana155Ja.I understand matirthe building
dms not curtemly h ascnant,ma it is my asponsihiloy m nodly Ira:ecomant of the
recut mcntswh' rootiniorwtam enlncauofOccupancyy. Signature of Applicant Date .
o n uthorizeJ agent Date All roof coverings to be Class "B" or better
. J A" -•_--•�, w-.,:-,-..,_+.rT.}:" ^q... .. vt�t..q....,.-r-rc,'^T•+--n•-.rss-.asp.-+.F.-m=,._.s„F.y---,..
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
acloF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRE PERMIT#6. D
bcc>
OWNER'S N PHO # Q
GENERAL CONTRACJ FAX #
I am not using any subcontract s: - C)
Signature Date
Please check applicable subcontractors and complete the following information:
60 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
z' Contractor Signature Date
J
CITY OF .CUPERTINO
TEMP POWER v
�UPERTiNO PERMIT APPLICATION FORM
APN# Date:
Building Address: p
Lff/i�L ud. �n
Owner's Name: Phone#:
Contractor: Phone: License#:
D 3 - -?
Contact: Phone: Cupertino Business License#:
1 G Jrt/
Building ermit Info:
Elect ❑
Job Description: — -..�
Residential Ef 0ornmercial ❑
Cost of Project: ruo
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ty. if
cable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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