04080123 ;BUILDING
Y OF CUPERTINO
BUILDING DIVISION' - PERT V�i\#1sF ,�l�l .. "•. ..
X4, e •
ADRESS: R K ELECTRIC INC PERMITNo.04080123
R'S NAME: PERMIT ISSUE DATE
NET
E:
SANITARY 2 ONTROL N0.
(510) 770-5660
ARCHITECT/ENGINEEIt: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION Job Description
y� F 1 hereby affirm Nat 1 am licensed under prewhiaos or Chnpmr 9(commencing ®®
n4 wide Senio ](1fYJ)erDivivon3of NCBusin and Professions Code.and myliccnse is A
EEEE in fullfom dcrcecL �/lfi�
LicensmCl af'—y('s Lk.R '4 _11 ,90 TI--UPS & OUTLETS FOR SERV
rat- Data '4-5j' hs Con" or
reqq ARCHITECTS DE ATION
1 understand my plana shall be used as public records
SEP130 2004
aio
3 W r Licensed Prefea ..I a,[
jO3 OWNER-BUILDER DECLARATION
.� I hcmhy.IBrm that I am exempt from the Cnmmnor'a License Law for the
00 following reason.(Section 71)31.5.Business and Professions Code:Any city or county
$�. which requires a permit to eanstmct. her,improse,d,moliah,nr repair any at..I re
FZmle prior In its issuance,also requires the applicant for such permit to file a signedstatement
F�
that he is licensed pursuant to the previsions of the Canlrutor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing wide Section 70D0)of Division 3 or the Business and Professions Cade)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section TM 1.5 by any applicant for a permit subjects to applicant in a civil penally of 3MT111lglbet00 Occupancy Type
Out more dean five hundred dollars($500).
1,u owner of the pmpeny,or my employees with wages u their sole compensation,
willdo the work end the senators is not intended cruised fusel.(Sec.7046,Business
and lambent..Code:The Contractor's License Law dean not apply to an owner of Required Inspections
property who bu ilds or improves thereon,end who does such work himself or through his
own employee,provided that such improvements are nut inmoded m.11craci forest..If.
however.the building or improvement is sold within one year of complevon.the owner.
buil&'will have she human of proving that he did not Wild or Improve for purpose of
sale.).
❑I,as owner of dee progeny,am exclusively connoting with licensed contractors to
construct On project(Sec.70",Business and Profusions Cade:)The Connectors Li.
ccuelaw doe not apply to an owner of property who Wilds or improves thereon.and
,who convects for uch pmjecm with a contractor(s)icensed pursuant to the Comaactars
License Law.
❑I am exempt under See. ,B&PC for this moon
Owner Data
7C37WWORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following doclermions:
have and will maintain a Certificate or Consent m elf-losum for WorkerbComp,n-
n,u provided for by Section 37W of the Labor Code,for Ne performance of the
k for whish this perlllll is Issued.
hate and will maintain Worker's Compensation Insurance,as required by Section
of One Labor Code,far the performance of Ne work for which this permit is issued
Workers ompensaatption Insurance carter and Palicy number amier. a'�p Policy NO:0Q
CERTIFlCATE FP.XEMMUNPROMWO KERS'
COMPENSATION INSURANC
(rossection bond not W eomplcmd ifthe permit is foram,hundred dollars(51 W7
or Ices.)
I calcify Not in the performance of Oc work for which this permit is issued.I shall not
employ any person in any manner an as in become subject to the Workers''Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,ofm making Nu Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of Rte labor Celle,you must
�z forthwith comply with such provision or Nis permit shall be deemed revoked.
zO CONSTRUCTION LENDING AGENCY
[-i (hereby air,.Nat Obert is a c...modian landing agency for the perform.....(
Cli> the work for which Nis Permit is issued(See.3097,Civ.C.)
Le car's Name
r7 z Loaders Address
IJ O 1 certify Nat 1 have read Nin application and stele dent dee eWve information is
IL c.re.L I agree to comply with all city and county ordinances and sum laws relating to -
0 U building construction,and hereby auNaries representatives or this city to toter upon the
above-mentioned property for inspection purposes.
(We)agree re rove,indemnify and keep harmless On City of Cupertino against
i h liabilities,judgments,casts and expense which may;.any way eceme against said City
r)Z in cansequbaca or On granting of this permit
^' APPLICANT UNDER AN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 URCE REG
Re-roofs
Sr attire ofAppla UClTHfikcmrHAZARDOUS MATERIALS DISCLOSURE Dat Type of Roof
Will the applicant tar future building nccupantsmre or handle haxodous material
an defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Coal,
Section 15531(a)1 1
C)Yen All roofs shall be inspected prior to any roofing material being installed.
u
Will the applicant or future building occupant tree equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
mit hazardous air contaminants as Jcfeed by the Bay Area Air Quality Management all new materials for inspection.
7cdxioes
istrict?
❑Yes No
1 have mad are insertions materials mg orcou n s underChapter 6.95 of the Califor-
iaHealth&Safety Code Sect 25505,25533 and 25534.I understand Naz if dos Wilding
not currently have a ren thm itis my mapoum ibility amiry the occupant of the
uircmcns wh;c .et priarm issuanceata c.rdnem oo.fffa.pony. Signature of Applicant Date
� C/�
Dam All roof coverings to be Class "B"or better
Owner tar am oris agent /
;BUILDING
Y OF CUPERTINO
BUILDING DIVISION' - PERT V�i\#1sF ,�l�l .. "•. ..
X4, e •
ADRESS: R K ELECTRIC INC PERMITNo.04080123
R'S NAME: PERMIT ISSUE DATE
NET
E:
SANITARY 2 ONTROL N0.
(510) 770-5660
ARCHITECT/ENGINEEIt: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION Job Description
y� F 1 hereby affirm Nat 1 am licensed under prewhiaos or Chnpmr 9(commencing ®®
n4 wide Senio ](1fYJ)erDivivon3of NCBusin and Professions Code.and myliccnse is A
EEEE in fullfom dcrcecL �/lfi�
LicensmCl af'—y('s Lk.R '4 _11 ,90 TI--UPS & OUTLETS FOR SERV
rat- Data '4-5j' hs Con" or
reqq ARCHITECTS DE ATION
1 understand my plana shall be used as public records
SEP130 2004
aio
3 W r Licensed Prefea ..I a,[
jO3 OWNER-BUILDER DECLARATION
.� I hcmhy.IBrm that I am exempt from the Cnmmnor'a License Law for the
00 following reason.(Section 71)31.5.Business and Professions Code:Any city or county
$�. which requires a permit to eanstmct. her,improse,d,moliah,nr repair any at..I re
FZmle prior In its issuance,also requires the applicant for such permit to file a signedstatement
F�
that he is licensed pursuant to the previsions of the Canlrutor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing wide Section 70D0)of Division 3 or the Business and Professions Cade)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section TM 1.5 by any applicant for a permit subjects to applicant in a civil penally of 3MT111lglbet00 Occupancy Type
Out more dean five hundred dollars($500).
1,u owner of the pmpeny,or my employees with wages u their sole compensation,
willdo the work end the senators is not intended cruised fusel.(Sec.7046,Business
and lambent..Code:The Contractor's License Law dean not apply to an owner of Required Inspections
property who bu ilds or improves thereon,end who does such work himself or through his
own employee,provided that such improvements are nut inmoded m.11craci forest..If.
however.the building or improvement is sold within one year of complevon.the owner.
buil&'will have she human of proving that he did not Wild or Improve for purpose of
sale.).
❑I,as owner of dee progeny,am exclusively connoting with licensed contractors to
construct On project(Sec.70",Business and Profusions Cade:)The Connectors Li.
ccuelaw doe not apply to an owner of property who Wilds or improves thereon.and
,who convects for uch pmjecm with a contractor(s)icensed pursuant to the Comaactars
License Law.
❑I am exempt under See. ,B&PC for this moon
Owner Data
7C37WWORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following doclermions:
have and will maintain a Certificate or Consent m elf-losum for WorkerbComp,n-
n,u provided for by Section 37W of the Labor Code,for Ne performance of the
k for whish this perlllll is Issued.
hate and will maintain Worker's Compensation Insurance,as required by Section
of One Labor Code,far the performance of Ne work for which this permit is issued
Workers ompensaatption Insurance carter and Palicy number amier. a'�p Policy NO:0Q
CERTIFlCATE FP.XEMMUNPROMWO KERS'
COMPENSATION INSURANC
(rossection bond not W eomplcmd ifthe permit is foram,hundred dollars(51 W7
or Ices.)
I calcify Not in the performance of Oc work for which this permit is issued.I shall not
employ any person in any manner an as in become subject to the Workers''Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,ofm making Nu Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of Rte labor Celle,you must
�z forthwith comply with such provision or Nis permit shall be deemed revoked.
zO CONSTRUCTION LENDING AGENCY
[-i (hereby air,.Nat Obert is a c...modian landing agency for the perform.....(
Cli> the work for which Nis Permit is issued(See.3097,Civ.C.)
Le car's Name
r7 z Loaders Address
IJ O 1 certify Nat 1 have read Nin application and stele dent dee eWve information is
IL c.re.L I agree to comply with all city and county ordinances and sum laws relating to -
0 U building construction,and hereby auNaries representatives or this city to toter upon the
above-mentioned property for inspection purposes.
(We)agree re rove,indemnify and keep harmless On City of Cupertino against
i h liabilities,judgments,casts and expense which may;.any way eceme against said City
r)Z in cansequbaca or On granting of this permit
^' APPLICANT UNDER AN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 URCE REG
Re-roofs
Sr attire ofAppla UClTHfikcmrHAZARDOUS MATERIALS DISCLOSURE Dat Type of Roof
Will the applicant tar future building nccupantsmre or handle haxodous material
an defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Coal,
Section 15531(a)1 1
C)Yen All roofs shall be inspected prior to any roofing material being installed.
u
Will the applicant or future building occupant tree equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
mit hazardous air contaminants as Jcfeed by the Bay Area Air Quality Management all new materials for inspection.
7cdxioes
istrict?
❑Yes No
1 have mad are insertions materials mg orcou n s underChapter 6.95 of the Califor-
iaHealth&Safety Code Sect 25505,25533 and 25534.I understand Naz if dos Wilding
not currently have a ren thm itis my mapoum ibility amiry the occupant of the
uircmcns wh;c .et priarm issuanceata c.rdnem oo.fffa.pony. Signature of Applicant Date
� C/�
Dam All roof coverings to be Class "B"or better
Owner tar am oris agent /