04010032 CITY OF CUPERTINO n **TT w�v
BUILDING DIVISION PERMIT CONTRAL^', 61ZMATIO� uJ',
BUILDINGADDRESS: RPD ELECTRICAL SERVICE CO PERMITNO04010032
OWNER'S NAME: PERMIT ISSUE DATE
AMELIA
ONE: SANITARY N0. CONTROL NO.
(408) 265-2850
ARCHITE=1ENGINEER
08 265-
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
B Q PLUMB MECH
0 0
u00 LICENSED CONTRACTOR'S derp DECLARATION Job Description
I�F I hereby to of that I am licensed under pd Pol ss of Chapter 9 ar,hear.is p
with Scnion]0(MI)af DivixionJ of the Be .v end Pmfcssinnx Cndc,end myliccnse is (IA/ill q qoo�
in full fore�an fleet. lt[JIl{J1R 2 L
�'qi ueenae Clg{.� G—to Lm.g DEDICATED CIRCUIT/OVEN HO
p Dem \-1—r94 Cummra�e'ar _❑
,e QQARCHITECTS DEQ ARATI N 1■l
y2 � yundcmta d my plans shallM used as public records BUILDING
Du
lT
o Licensed Pmfissional
OWNER-BUILDER DECLARATION
<y I hereby affirm that I am exempt from the Comeacmr's License Law fur the
p 0 following reason.(Section 7W L5,Business and Professions Code:Any city or county
K$ which mquirrs a pencil ht construct,altar,improve,demolish,or repair any,structure
°`y poor it)its issuance,also requires the applicant for such permit to flc a.sigocd statement
'Ps< that he is licensed pientuat to he provisions Of the Centocor''s License law(Chapmr 9 Sq. Ft.Floor Area Valuation
yNO (commencing with section 7M)of Division 3 of the Business and Professions Code)or
y r3$
that he is eaempl Rerefmat and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for apnm;I subjects the applicant to a civil penally of 341�Bi21Vl@T1Aer00 Occupancy not more Nen five hundred dollars(5500). Pane y Type
0 1,as owner of the p urany,or my employees with wage,as their able compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Commences License Law does not apply to an owner of Required Inspections
property who builds or Improves thereon,and who dmasuch work him tairm through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement Is sold within one year of completion,Ne owner
builder will have Ne burden of proving Nal he did not build or improve for purpose of
"to I
❑I.as owner of the properly,am exclusively contracting with licensed contractors to
compact the project(Sec.7044.Business and Professions Code:)The Charterers U.
came Law does not apply to an owner of property who builds or improve Nemon,and -
who contracts for such projects with a comeanor(s)licensed punuanl to the Contractors
License 4w.
❑I am exempt under Sec. ,B&P C for this motion
Owner Data
WORKER'S COMPENSATION DECLARATION -
1 hereby grim under Penally of perjury one of the fallowing declarations: -
1 have and will maintain a Cenifnle of Consent to sel6imure for Workers Cornam.
7371M
ion,m provided for by Section 3]00 of the LOW,Code,for the performance of the
rk for which this permit is issued.
1 haw and will maintain Worker's Compensation Insurance,as required by Section
of Ne Labor Code,for the performance of the work for which this permit is issued.
Worker's Compensation Insurance carier and Policy number art: ^1'E $1LCTup2FMFM[(icyNo�-
]•' CERTIFICATE O-FEXEMP�ONFR RKERS''
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundmd dnllms($]W)
or leas.) '
1 certify that in the performance of the work for which this permit is issued,I shall not -
employ any person in any manner so as in become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccrttfcatc of Exemption,you should -
become subject to the Worker's Compensation provisions of the Iahar,Code,you must
.JO foMwith comply with such provisions or this perm!"hall be deemed revoked.
'yM CONSTRUCTION LENDING AGENCY
[—tom I hereby alTom Nat Nem is a consructinn lending agency for Ne perfoonancc of
ori Ne.,it fur which this permit Is issued(S..3097,Civ.C.)
W� Q Under'.Name
Lender's Addmm
U Q 1 cesify that 1 haw read this application and stem that the above information is
14 F correct I agree b comply with all city and county ordinances and sate laws relating 10
C U building construction,and hereby aathorife representative of this city to enter uponthe
W ahowtms,judgdpro,sitycost for inspection purposes
gL (We)agree to wa,.indemnity and keep harmless the City of Cupertino against
h incro0aa,judgmentaecraning expenses which may in anyway accrue against Said City (a'
(„) ,'� inconsequence of UNDERSTANDS
of this permit.
F-t APPLICANT UNDERSTANDS A WILL COMPLY WITH ALL NON POINT Issued by: Dale
SOU ATIONS. /%
Stcf Appbcant/Commeour Date Re-roofs
�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant sore or handle hamrJous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
CoJc.Section 25532(e)?
Ycs KN. All roofs shall be inspected prior to any roofing material being installed.
U
Will the anpbnm or rnmm bnBAng ar spam gab equipment or aemn,which
If a roof is installed without first obtaining an inspection,I agree to remove
nit hazardous air contaminants m dcfmcd by the Bay Arca Air Quality Management all new materials for inspection.
is strict?
❑Ye. 4No
1 haw mail the hassdous materials requirements under Chapter 6.95 of the Califon
ria Health&SafetyCude,Sections25505,8533and255J4.Iundc.t thsifthe building
does not eur4ndiy have a tenmt th t' u my meant ihility a modify the occupant of the
requiremc hich must be met mance ofa Cent am of Occupancy.
Y Sig Date
or authorized agent Date All roof coverings to be Class "B" or better
CITY OF CUP TINO
CUPEkTINO PERMIT APPLICAT N FORM
APN# S4 2 3z D$ Date: I
Building AI dress:
Owner's Na e; Phone#:
fl m n 40q y
Contractor: License #:
RPDr e otons I q LO
Contact: Cupertino Business License#:
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Building Permit Info:
Bldg ❑ Elect " (/
Job Description:
�e
Residential: Commercial: ❑
Cost of Projec Monument: ❑ Mounted on Building: ❑
a le Fee ID Fee Description Fee Group
BENERGY Eneru BUILDING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BSEISMICOM Seismic Commercial BUILDING
EPERMITFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmdl Sings, Marquee ELECTRICAL
BUSLIC Business License BUILDING
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