04010164- CITY OF CUPERTINO"'
< �'� x�
t CONTRACTOR 14F6'RMATIQIV:
- "_•;
-
BUILDING DIVISION PERMIT
au ILDING ADDRESS:
n33o STERN AVE
NATIONAL CONSTRUCTION RENT
Ptt, IT NO04040164
OWNER'S NAME:
PERMIT ISSUE DATE
BARBARA BERNIE
115c; FILIPE AVE
ONE:
SANITARY N0. CONTROL NO.
(818)221-6057
ARCHITECT/ENGINEER:
BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S provisions DECLARATION
Iherebyarum thatI.m0cee Chapter v
- Job DeseriptipnR
Buinss ndProwof
is
with Semce mntp of Division ] of the Business end Prufcuians Cntle, and my license is
my
BII""'"'ll7i tl Wl 4f�.�
mmne erre"
TEMP POWER POLE
Class
Dole Class Contract., Dole CanlrECL
MAY 10 2004
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
-
BUILD-sNG
Licensed Professional
OWNER -BUILDER DECLARATION
Law for the
1 hereby a(See that I am exempt from the Cs.0ors
oLicense: c
following (Section ]nota ,Business and Professions Code: Any city county
a.
requires
which requires a Pcrmil In cnnaruct, mteq improve, demolish, Or repair any ,atruaurc
him
Prior In its issuance, also requires the applicant far such permit to file a.signed statement
that he is licensed proton, m the provisions of the Contractor's License Law (Chapter v
Sq. FL Floor Area Valuation QQ
(commend ng with Section 7") of Division 3 of the Business and Professions Codc) or
Nat he is escort hea(mm and the Nuia for me alleged exemption, Any viondon of
Section 7031.5 by any applicant for s permit subjects the applicant o a civil penalty of
3'7�AI4�Tber00
Occupancy Type
not more man five hundred doRan($500).
P Y
El I, as owner of the property, ar my emploYces with wages m their sole compensation,
will do the work, and lie structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
Required Inspections
property who builds or improves thereon, and who doesauch work himself orthrough his
own employees, Provided that such improvements are not intended or offered forsale. It.
however, lie building or impervermint is sold within one year ofcompletion, the owner.
builder will have the burden of proving mat he did not build or improve for purpose of
sale.
I, as owner of the property, am exclusively contracting with licensed contractors to
struct the project (sec. 7W, Business and Proleachns Code:) The Contractors Li.
cense law does not apply to an owner of property who builds or improves merver. and
who contracts for such projects with a contmcter(s) licensed pursuant o the Contractor's
License Law.
❑lamex pt under Sec. B& P CC for thhiiss...n/_
_
Owne Dated
WORKER'SC PENSATIONDECLARA IS
I hereby affirm under penalty of perjury one of the following declarations:
_
I have and will maintain a CCM1IacaN of Consent la Self-Insum far Warler'aCompFn-
S ion, as provided for by Section 37W of he [abut Code, for the performanre of the
work for which his permit is noted.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
PlW o(the labor, Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number ate:
Cartier, Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectio need ampecomple ed Bits, Permit is for one hundred dollars ($INN
less.)
1 terrify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Wtrkerfi Compensation
Lava of California. Data
Applicant
-
NOTICE TO APPLICANT: If, after making this Ccrri licate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
foMwi to comply with such provisions or his Permit hall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a cmnmmecon lending agency for he performance of
he work for which this permit is issued (Sec. 3197, Civ. C.)
Lender's Nam.
Lender'sAddress
1 certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws aiming 1.
building conmmetion, and heavy authorize representatives of this city to enter upon the
shove -mentioned Property for inspection purposes.
(W.) agree to save, indemnify and keep harmless the City of Cupertino against
Stats and expenses which may in any way accme against said City
in consequence
A canacqucnc. of the
nofthe of this permit.
UNDERSTANDS
APPLIC T UNDERSTANDS AND ILL COMPLY WITH ALL NON -POINT
Issued by: Dale
SO REGULATIONS. .,'
Re -roofs
® /.1
Typo Of ROOF
a
gnaturcof ApplicanurCoatmctor Dam
HAZARDOIIS MATERIALS DISCLOSURE
Will stare or handle al
or forumbpalCode.
7 (�
by the Cuperri,ant
as de Setl by the Clding aret
nu Municipal Code. Chaprer 9.11, and the Health and Safety
Throtousmaoety
Cndc, Section 25532(a)?
32(a)?
rYes ❑No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
it hazardous air contaminants u defined by the Bay Arca Air Quality Management
all new materials for inspection.
is0ict?
❑Yes ON.
I have read the hmaojuusmaterials requirement under Chapter 6.95 of the Collins,
id. Hcalh&Safmy Cede. Sections 25505,25533 and 25534.1understand thmifthe lmilding
does not -umently have a octant. Nat it is my ms ansihility to notify the Occupant of he
requi t bichmatbemetpdarthiaau e. onecmrkateafa.Pan..
`
Signature ofApplicant Date
All roof coverings to be Class "B" or better
ncr, or authorized agent Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
TOB ( 3�OS•�2.lJ
0
PERMIT #�
6
OWNER'S NAME: AA/->AoIA e>e42- IE
PHONE # 22/6
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors: (0 /(
Signatur Date
Please check applicable subcontra ors and comnlefP fha {rowing infnr nfinn-
�er/Contra�c or 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
Pcl u
7 OPAL P4Fa /
�er/Contra�c or Signature Date
CITY OF
UPEkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
,-Z�.�b/�`
APN #Date:
3-75-14- 0
Temporary Power
ELECTRICAL
Building Address:
l0 30E
Elect. Permit Issuance
ELECTRICAL
Owner's Name:P
Business License
one -
�{ k42
�
59713-22�
ontxactor:
(z--
Phone- —10
License #:
Q Z % Z
ntact:
Phone
'Gepertino Business #:
NZ I 2c1
S 315382
_License
uilding Permit Info:
Elect ❑
Job Description:
Residential
Commercial p
Cost ofP cject:
20�
•
Qty. if
Nnnlicnhle Fee, M
Fee Descrintion
Fee Groun
BTEMP
Temporary Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
2s 3c>?f
*q3,d 2--