03090234 CITY OF CUPEW11NO "' *aa-. .� 'r �.,a��t v � r• "
BUILDING DIVISION PERMIT ON.TRACTRINF�O^ RMATION:
BUILDING ADDRESS: PERMIT NO03090234 3O9O234
nqc;n STRITENS CANYON RD
OW NF.R'S NAME: PERMR LSSUE GATE
N SANITARY NO. CONTROL NO.
�a}GL�� 7$� —0555
AR:111TECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 t�
00 LICENSED CONTRACTOR'S DECLARATION Job Description
I um C 1 h cby Sir, that I em licenud under provisions of Chapo:r Y(commcndng p
I<a. withI oda)o(Diviaion3of the Business and Pwfcuiuns Codc,end myliccnx is
.�< o semi cander�ey. 46,2e570 TEMP POWER POLE
ttfi,? ma, Class Lie.a w o "
Dat Coma r CONTRACTOR: NAVICO, INC eV�
~¢¢ ARCHITECTS DEC ION
WI un rstanJ my plant shall Ire used es pis rtcnma
.p Licensed Professional OC ' J 903
OWNER-BUILDER DECLARATION
J<x I hereby afford that I am exempt from the Contractor's License Law for the
:0 O following reason.(Section 7031.5.Business and Profession.Code:Any city or county
5$ which requires a Fcmril to cauvuct,alter,improve,demolish,or repair"any Stwctum
-ZY prior to its issuance,also requires the applicant for Such permit to file a signed sulemenl
3xp that be is licensed prroom I.the provisions of the Cmuacum's ldn
cex Law(Chapter 9 Sq.Ft. Floor Area Valuatlo$500
2a- (commencing with Section 7000)of Division 3 of the Business and Pmfcasions Coat)or
$ that he is exempt therefrom and the buss for the alleged exemption.Any violation of rn,n�7ecf7 t.vw..,h
Section 7031.5 by any applicantfors permit subjects the applicant to.civil penalty of 3DSD)Nn4lbu00 Occupancy Type
not more man five hundred dollars(S500). P Y YP
❑I,as owner or the propcny,or my employees with wages AS their sole compensation,
will do the work,and the Structure is not intended or onered for sale(Sec.7W.Businese
and Professions Cade:The Contactors Lieenx Law dao not apply a an owner of Required Inspections
property who builds or improves outman,and who dors such work himselror through his 103 — UFER �'Np��pL.��
Own employera,prorided tw
hnch improwmentsare d se
notimanded oroffcrer ale.If. 304 — ROUGH ELECTRICAL
however.Ne building or improvement is sold within one year of completion,the owner.
builder will haw the burden of proving mat he did not build or improv far purpose of
ole.) OCT 15 2003
❑ I.as owner of the property,am exclusively contracting with licensed contactors to
construct the praject(Sec.7644,Business and Profusions Code:)The Contractor's Li.
cense law does not apply to an owner of pmperty who Wilds or iroprova thereon,and �Op'y as�I�/�,
who contracts for Loch projects with a cononclmto(s)licensed pursuant the Convecutor's W tai
LKeax Law.
❑I am exempt under Sec. B k P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self insure for Worker,Cumpem
kation,u provided for by Section 37W of the labor Code,for the performance of the
work Tot which this permit is issued.
❑ 1 haw end will maintain Workeri Compensation Insurance,u required by Section
31gJ of the lobar Code.for the performance of the work for which this permit is issued
My Worker Cn pemation Insuanco Son, d Polu, number arc:
Cem'ep otic p.:onl] �— ODS
✓\y CERTIFICA �OF EJEMPn OM WORKERS'
COMPENSATION INSURANCE
(Thosee ion need not W eamphoed if the permll6 Tmorm hundred dollen(5100)
m leu.)
1 ccnify thm in me performame of da work for which this permit is issued.l shall out
employ any perwn in any manner w as a become wbjecuo 11he Workers'Compensation
Laws of Ci lifomin.Data
Applicant
NOTICE TO APPLICANT:It,after making this Cemfaate of Eaemption,you should
WCnle Subject a the Worker's Compensation provisions of the Labor Code,you must
70 forthwith comply with Such provisions or this permit shall W deemed revoked.
r y CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perfurmanee of
Yr > the work for which this permit is issued(Sec.3(97,Cih,C.)
S7 Q Landers Namc
Z Under.Add.
Q 1 coniry that 1 have read this application and nam that the nWve informa0un is
y F coned 1 agree 10 comply with all city and county ordinances and stale laws relating to
U building aonstwaion,and hereby authorise representatives of this city to enter upon the
4 ,how-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupcfthm against
rn liabifltu,judgments,casts and expcues which may in any way&code against said City
in of the gmnti ng of
his
J z APPLICANTcUNDERSTANDStAND WI COMPLY WITH ALL ON-PO NT Issued by: Date
SOURCE REOULA
M 9 � j
Q Re-roofs
gnaws of Appliun onvactor Data,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applican,or future building Decorum nate or handle hamohms material
u defined by the Cupmi no Municipal Code,Chapter 9.)2,end the Health and Safety
Code,Olv.25532(e)? No All roofs shall be inspected prior to any roofing material being installed.
Wilt the applicant or future Wilding occupant uxeyuipmcm orJcvices which If a roof is installed without first obtaining an inspection,I agree to remove
it hvardous air contaminants a defined by the Bay Area Air Quably Management all new materials for inspection.
❑Yes
1 have mad the hovardous maarials requirements under Chapter6.95 of the Califor.
nia Health 6 SafelyCWe,Sections 25505,25533 and 25534.1 undersand that if the building
docs not currently hove a vnam,thm it u y responsihilily m nobly the meupenl of the
reyuiremenuwhi m Icmu d aneeonCedaeat rOa Signature of Applicant Date
acne sholumixdagcnl aDaa All roof coverings to be Class "B"or better
CITY OF CUPERTINO d 2 3
,Scu% ,
TEMP POWER U 3
WUP61CTINO PERMIT APPLICATION FORM
APN# �� Date: 9 /;�(,j 0
3
Building Address: (2kn l o n Q-4
Owner's Name: �aViLa � Zn Phone #(408) 7#)
Contractor: Phone: License #:
Contact: -31 rC e-\ Phone: 74 ' _0 S Cupertino Business License#:
BuiPermit Info:
Elea-
Job
escription:
Residential Co mercial ❑
Cost of Project:
Qty. if
,Appli Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING