04120063 CITY OF CUPERTINO
BUILDING DIVISION PERMIT G0NTRAGTnRI7NFORMATION ;
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BUI LDIN'GADDRESS: R K ELECTRIC INC PERMIT NO.04120063
OWNER'S NAME: PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
(510) 770-5660 ARCHITECUENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
leo LICENSED CONTRACTOR'S DECLARATION- Job Description
I+m 1 here, aM IMI 1 em lieemcd under p Sons of Chip e,9(commcnems P _
n� with Scclioa )of Dlvision0ofthc Bassi.il/Prurauimu Code,eod my licrnsc is
inmllfo defreel. !/v O GEN. /SET FOR TRANSFER (BASEMENT)
Llcen Lk.a
J Dam Con Vector till IttT{����1&t //�� t{�,.A,,
C las rad mY plant CHAP used a cnrJ F G II X17()TY�L E D
y aaa VVV(/ N ;S;"M
yU
r0 Licensed Pmfcuio
yOW R-BUILDER DECLARATION
gADD
I I hereby affirm Net I em e.cmp fru.de Contraaars Licence Law for the APR s10Dc
00 following reason.(Section 7101.5.Business and Professions Code:Any city or county ( v7
which acquires a permit m enn.truel,aIucr.improve,demolish,at repair any stratum
prior to its issuance,also requires the applicant rat such permit to file a signed summeal
In,,M is licensed pursuant to the povisiomnf the Contractor's License Law(Chapler 9 Sq.Ft.Floor Area e VaU i1DQ
2'y zC0 (commencing with Section 7000)of Division 3 of the Businces and Pmfcaalons Code).,
L 3 that he]A escmpl Nemfrom and the basis for the%[]cited exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to A civil penalty of 3��210�IbkC 0 0 Occupancy Type
not acme Nen five hundred dollars(5500).
❑L u e work.
of IM property,re my of amended with wages .their sok compenutkn,
will do Ne work,end Ne ed Conso not,Lt.OoroRereoes.1a ply 7041,Boners Required Inspections
end Professions Codo:The Contrumrs rad who Lew docs not apply to an owner of q P
property who buildsvi Mpravesch imps endwho dmssuchwork himselfedthrough his
own employees,provided pr metaimprovemtnstin not intend
ed for Meask.IL
however,ill haw
or improvement sold within of year of c prove on,for N purpose
r.
of
builder will have dm burden of proving Nal he did not Wild or improve for puryose of
sale.)
.
❑1,as owner of Out property,am exclusively contracting with licensed contractors In
construct Me project(Sec.7044.Business and Profasiom Code:)The Conuactors Li-
cense law docs not apply 0 an meet of properly who Wilds or iosprom daemon,and
who comments for such projects with a contractor(,)licensed pursuant to the Cmtraclor's
License Lew.
Oram .,mpt under Sec. B k P C far Ni,reason
Owner Dam
WORKERS COMPENSATION DECL RAT10N
I hereby affmml under penally of perjury om of Ne fo0awing decleratione:
1370M
ave and will maintain a Certificate of Consent to self-in..m fmWorkee.Compen-
,u provided for by Section 3700 of the Labor Code,for the performance of the
far which this permit If landed.
have And will..Intel.Wahees Compe.d..Ineurence,u required by ScNn.
ofNe IaborCode.fm the performance of Ne work fm which this permit is iumd.
aheh Ca^y�n�tioy,�nsuranc artier and Pol'eymma 'am:
e li }k.k. Polity Na {VMa�As Z�J
CERTIFlCATEOF fEMPI70N FROM JJORKERS'
COMPENSATION INSUR N
whit section need rot W completed if the parol m oro hundreddo1lau(il0i
M kis.)
I certify Met in the performance of dm work for which this permit is issued.I sM11 not
employ any person in any manner an as to bmome subject in the Workers'Compensation
Law s of California.Dam
Applment
NOTICE TO APPLICANT:IL after making this Ccrtifream of Exemption,you should
become subject to M Worker's Compensation previsions or the labor Code,you most
=0 forthwith comply with such provisions or this permit shell he deemed revoked.
CONSTRUCTION LENDING AGENCY
I Mmby arum NU Nem iso construction lending.gemy for ft performenm of
1' the wash for which Ws permit 6 iumd(Sm.30D,Civ.C.)
Q Lenders theme
z Lender's AM.
:)Q 1 certify that l have reed Nis application and mm Net tiro above information Is
FcomacL I kitm to comply with all city and county otdinanea end stale Tawe relating to
building construction,and hereby authorise representatives;of this city to color upon tiro
Na .hove-mentioned properly,for impection purposes.
r (We)agree to save,indemnify and keep harmless the City of Cupertino against
In Ilabilide,,judgments,coast and expenses which my in Any way ammo Against said City (/
J in consequence of the gaming of I 's permit. !
APPLICANT UNDERSTAN ND WILL COMPLY WITH ALL NON-POINT Issued by & Date /
SOURCE REGUL N
Al"If Re-roofs
Sig Plies
of Pican amounts - Due
AZARDOUS MATERIALS 01 C�SURE Type of Roof
Will the applicant or future building mcupenl uorc or handle huallous material
as defined by the Cupenino Municipal Code,Chapter 9.11.and the Health And Safety
code,Second25532(.)? Na All roofs shall be inspected prior to any roofing material being installed.
Will Me.Ppli...I or�re building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I haatdooa oI,contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
oriel'
C]Yea o
I have mad Me and .mater srtquirtmenu unikrCMpkr A95 of Ne Califor- i
niaHalN@SeferyCade,5u4wu .15377 AmI153Jd.IuMeuwd Nuif the Wilding
does currently have e te rot is my responsibility m nod ry Ne occupant of the
red cnstwhich p rtoiuuanccoffCenifmslo f cu ey. Signature of Applicant Date
"�� Owner urawhor". col f Das All roof coverings to be Class oBo or better