04070071 7-1
CITY OF CUPERTINO _-
BUILDING DIVISION PERMIT C7�'.RAC`"TCIRTN +',UR'1VIATTON' �'
BU ILDING ADDRESS: PERMIT NO
STEVE NAN CONSTRUCTION 04070071
OWNER'S NAME: PERMIT ISSUE DATE
ME
ONE: SANITARY NO. CONTROL NO.
408 2
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
:Op LICENSED CONTRACTOR'S DECLARATION
U¢ 1 ha by affirm that I em licenced under Previsions of Chapter 9(commencing Job Descrip on
n¢ with Soodo.T(IW)of Division Sof the Beat...and Proaaiu
fens Code,and my license is
ow infull force and effect. TEMP POWER
,n� License Clazs Lic.p
Dam Convector
ARCHITECTS DECLARATION
I understand my plans shall M used u public meet&3�1 ;r4r_'_C,
,W� Licensed Professional
OWNER-BUILDER DECLARATION
i<I 1 hereby aid.that I am exempt from thm Contractor's License Law for the
H2 following reason.(Section 7031.5,Business and Professions Code:Any city or county
3 which requires a Permit m commas.elm,improve,demolish,or repair any gacmm
prior to its issuance.also requires lheapplicanl for such permit o file a signed statement
a
that hcisHamad pursuant tothe provisi000fthe Contractor's Lwors.Low(Chapter 9 Sq.Ft. Floor Area Valuation
e (commencing with Section 7(00)of Division 3 of the Business and Professions Code)or
$
F Nat he Is exempt therefrom and me buss for the alleged exemption.Any violation of
Section 7831.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 S�NQ'd1filr6er0 0 Occupancy
. sot more Nan five hundred dollars($580). P Y Type
El r.
I,as owner of the property,or my employees with wages as their sole compensation,
willdo the work and the swcrure isnotimmndedoroffemdforsale(Sec.70 ,Bulinus
and Pmfaramns Code:The Conuacmis License Law dose not apply to an Owner of Required Inspections
property who buildsor improvedmog ,and wbodoessuchwork himselforthrough his
awn employees,provided that such improvements are not intended at offered forage.If,
however.the building or impmvement is sold within ane year of complcdon,bre
owner.
Nowner-
builder will ban burden of proving used he did not build or Improve for propose of
soh.).
1.as owner of the property,am exclusively contacting with licensed contractors in
nswct the project(Sec.IDs.,Business and Profusions Cade:)The Commerce,Li-
cense Law does not apply in an owner of property who builds or improves thamon.and
who contacts for such projects with acontracmr(s)Ila c1puauantmthe Commutes
License Law.
❑Ism uempt and , ,B&P C for this moon
Data /
WORKER'S COMPENSATION ION
hereby arm under penalty or perjury,one of the following declarations:
I have and will maintain a Ccrtifimm of Consent m self-insure per WorkelaC.mpen-
mime,o provided for by Section 3/80 of Ne Labor Code,for the performance of me
work for which this permit is iuuM.
❑I have and will maintain Worker's Compensation Insurance,o reyubed by Section
3]00.1'me tabor C.
for the performance ofthe work forwhich this permit is issued.
My Wo tan's Compensation Insurance carrier end Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPT10N FROM WORKERS'
COMPENSATION INSURANCE
('Ihisuction need notMcompleted If the Permit is franc hundred dollars(5100)
or leas.)
1 certify mal in dre performance of the work for which this Permit is issued.I shall not
employ any person in any manner an az to become subject to the Worlo rs'Compensallon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you mug
.J O fmshwith comply with such provisions or this permit shall be deemed onnked"
,z.,h CONSTRUCTION LENDING AGENCY
[ter I herebysflirm that mere iaacoownion lending agency forme No(.....f
f�n>-r the work for which this permit is issued(Sec.389?,Civ.C.)
A Lender's Name
Z)z Lender's Address
V Q 1 certify that I have mad this application and stem ma the When infonmai m is
11,H correct I agree to comply with all city and county ordinances and sok laws misting to
O V Wilding construction,and hereby summon representatives of this city to enter upon the
G ahovatim, dpropertycosts
for inspection proposes.
(We)agree to save,indemnify and keep harmlmas the City of Cupegino against
in consequence
nceofjudgments.cats and of this
match may in anyway accmc against said City
U
APPLICANT UNDERSTAthe NDSIAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CEREGUL NS.
7 Re-roofs
Si not ApplicanVContromr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building caupanl slam or handle harudous matarial
az defined by the Cupertino Municipal Code.Chapter 9.1;and me Health and Safely
otic, C]Yo9 25532(a)T AN.
All roofs shall be inspected prior to any roofing materi being installed.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant 1'w building occupant ago or device which g p g
it hausrdro air contmO 6 u dcMN by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes u
Ihavemadthehaa usm crisis requirements under Chapter 6.95ofdie Califor-
ma Hcolm&Safmy Cod,Sccd.o MO5,25 33 and 35530.1 undcrsmnd dmirme building -
does not currently have a tenant mar it is rcaponsihility to artily me naimem of the
requirements whw . m l rl. mocanra mficauamaaparcy._ Signature of Applicant Date
---/
0authomntl agent Dam All roof coverings to be Class "B"or better
r
CITY OF CUPERTINO
TEMP POWER
OCUPERTINO PERMIT APPLICATION FORM
APN # ?/ Date:?
✓J cf� —/ —O
Building Address:
Owner's Name: Phone#: p
6Eo —fit �8/
Contrator: Phone: lso� 2a33�33 License#:
S vt4 law 6 9 3
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description:
Residential 6K
ommercial
Cost of Project:
Appfc ble Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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