03040050 CE
RTINO -
'( ISION PERMIT COM,VAA—TOVA!NFO'RMA�TIO.N
OUIPERMIT NO.
a
TEVENS CREEK BLV EVERGREEN 'DC' CO ,(LHC) ' 03040050
OWPERMIT ISSUE DATE
UNDAVAJHALA 6619 DANRIDGE DR. 04/08/2003 ,SANITARY NO. CONTROL NO.
(408) 887-0186
H17ECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
o C= 0 0
Sop LICENSED CONTRACTOR'S DECLARATION Mp
Job Descri tlOn
1 eby affirm Nat 1 am licensed under provisions car chapter 9(cemg recoe her
with Section 7010).1)10,19 urine Business and Professims Codo,and my licenw is
Infullfarmandcffect. -
Limes,Cl —LI
�- `6 TEMPORARY POWER
n Oam — C.rImCbr l�
' AR 1'fECi'S DELLA ON
luedcrsundmyplw ahallbeuwd crcmrm !/ /
5 Licensed Pmfcubmal / D
OWNER-BUILDER DECLARATION
1 hereby afRs that 1 m
p$Olieexempt from the CnntractaLew for the
followingmass. m ]131.5,Business and Professions Code:Any city or manly
which requires a Permit sracnnstru4 a@a improve.demolish.or repair any
cture
aro.Cut a poor In its issuance.also mqums the applicant far such permit m rile a signed anlcmcnl
F < thatheiflimnudpunuenttothepmvislmunfdr,ContractarsLlem.law(Chapter9 Sq.Ft.Floor Area V1 atton
ySCS (comm0)
encingwithSecdan710nfDivision3oftheBest.andPm(cuinnsCode)or 250W�0
3 dart he is exempt Therefrom and the bub for the alleged esempdon.Any Aerialon of
Section 7D31.5 by any applicom for a permit subjects the applicanf3
to a civil Penally of �11N a Occupancy Type
not mom Nen rive hundred dollen($500). 1r0 T7yeP
❑1.as owner arms property.or my employees with wage As their ole compensation, "
will do the work,and theaeucture is not Intended m.scrod fonato(See.7044.Business
And Professions cane:The Contractors License Law doe,not apply to an aware of 103 - UFER Required Inspections
property who builds or imlo.vthcrcan,and whodousmh work himciforlNough his
o304 - ROUGH ELECTRICAL
wn employees,provided Net suit improvements are not Intended creamed fmsale.If.
however.the building or improvement is sold within ons year of eompledon.the owner. '
builder will hove she burden of moving Nn he did not build or Improve for purpose of
wlc.I.
❑1.ee owns of the property am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's LI- .
cense law does not apply to an owner of property who milds or improv IAeman,and,
who contracts for uch projects with acoma cmr(s)licensed pursuant to the Contractors
License
Law.
❑Iamexempiunder Seo. - ,B&PCfar Nlsmason -
Owner Dote -
WORKER'SCOMPENSATIONDECLARATION —
1 hereby affirm under Penally of perjury aro of site following dechaulma: -
�, haw end will maintain(CeNOcate OFC...,to self-Insure for Workers Compsm.
n,u provided for by Section 3700 of the tabor Code.for Ne Performance of the
€.l ark for which Nb permit is issued.
z ❑1 have and will maintain Workers Compensation Insurance,sa required by Section
3700 of the labor Code.for the performance or the work fm which this permit is Issued.
My Workers Co� Ion Inaunom esmler end Policy numk,am:
Cartier. — Policy No.: -
CERTIFICATEOFEXEMPfiONFROM WORKERS'
COMPENSATION INSURANCE
In IaSL)(This we need not becompleted if the Permit is for one hundred dollars(5100)
... 1 certify Net in the performance of the work for which tibia permit is Issued,I shall nM
employ any pawn in any mannerw u An become subject to thcwohers'Compemnlon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should r
became subject m the Waiter's Compensation provisions of the labor Code,you moat
forthwith comply with such provisions m(his permit shell he deemed revoked. - -.
Z O CONSTRUCTION LENDING AGENCY
I hereby elrmm that dem is a cmutructinn lending agency fm the Pcrrormnme or
x� the work far which this permit is issued(Sec.31197,Civ.C.)
Y Q Lcndces Name
Lender.Add.
J Q I«mfy that I have read Nis application and cute that the shove informals is -
y correct.1 agree to comply with all city and county ordinance and state laws rcletng to
SV' building construction.And hereby authorize repwwnutiv or Nls city to enter upon Nc
above-mentioned pmperty for Impaction purpose,
4 y (We)agree to saw,indemnify and keep harmless the City of Cupertino gainst
t/) liabilities.judgments,coo and expemes which May In any way amuc against said City
J7 in consequence of Ne granting of this permit
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
'p- 1,A) Re-roofs
mute ofApplicaUConnctor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant Yore or handle huardow material
as dented by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant building.cera amuse .'If a roof is installed'without first obtainingan inspection,I agree to remove
PP 6 p equipment or devices which P g
L hamdous air contaminants As dcOncd by the Bay Arta Air Quality Management all new materials for inspection.
7
' ❑Yes ❑N. -
1 haw mad the hvamnusmaterials uqubemems under Chapter 6.95 of the Cabral.
niaHenlNg:SafetyCoek,Sodom 25505,25533 and 25534.1 understood that ithe building -
does,not currently hem a mount that It Is my responsibility 0 notify the u areal Of Ne
r .lromanuwhich most the met poor wlssusaeeoraC[nlrm.m.rOccapany, Signature of Applicant - Date
r.atn.rired epenl All roof coverings to be Class"B"or better
r
CITY OF CUPERTINO
1t TEMP POWER
CUPERTINO PERMIT APPLICATION FORM 03)�05Z
'APN# 'A
Date:
0-D
Building Address:
l�3 Ste ueti s Creek rt-%d Cil
Owner's Name: Phone#:
A u vA ' Wc-\ VoR- 2-C7 — L 6
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
a 2 i J _ � 54 g&e , �o Abb v�
Building Permit Info:
Elect ❑
Job Description: /v�� 11 �—
"PM)
Residential Commercial ❑
Cost of Project:
Z . 6rD
Qty-1-1f
Appfile, Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License "BUILDING
ff02-
t