04060110 CITY OF CUPERTINO
BUILDING DIVISION PERMIT COIV"C12ellTR I> aUR1Vx'A.TT01�I:
BUILDING ADDRESS: PERMIT 104060110
OWNER'S NAME: PMMITLSSUEDATE
LTNr YANr 06 114 12004
ONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 o
Loo LICENSED CONTRACTOR'S DECLARATION -
Zw 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Descrlp O
a'
with
Secries7Md).f Division Sof NC Business and Profusiuns Codc,end my license is
it mu rorce.ntl arca"' TEMP POWER POLE
5 License Class sec.p
Dau TS Contractor �
ARCHITECTS DECLARATION 'V �V-
1 undersand my plans shell be used as public records
3 Licensed Profesaionel ?0
OWNER-BUILDER DECLARATION
0 1 herchy.(firm on 1 em exempt from the Cssions Code:License ty o for Ibe Al
p O fallowing moss. ermit t A1nstr Business and ve.de o li h,orAny city or county
which requires a issuance,also re scares be applicant
Wpave,demolish. file
repair ed structure Y,8
��<uS prior uits ensedPts.rcquiene lbeisions o for such C.amurr's im .Lacda.mmcnl
than wJ puecuam to the of Divine oftheBusiness
nd Professions
(Charlene? Sq.FL Floor Area Valuation-
(commencing
s $ atitsannul tSereion rom nd of Oivisian3 nfnWeg.d meand Professionsladan of
3 Nm he u exempt therefrom and the beau for Ne alleged cuicant t.Any violads of
Section than by any applicant for a permit subjects the applicant to a civil penalty of 3�e10 O OCCU anC aryl e
not more Nen five hundred dollars(E500). P y ']P
❑I.as owner of Ne property,or my employees with wages as their sole compensation,
will do the work end the structure is not intended or offered forsale(San.7044,Business
and Peninsula.Code:The Contractors License Law doe not apply to an owner of Required Inspections
property who builds or i m proves lhemon,and who doss tech work himsel f or through his
own employees,provided than such improvements;art not intended mattered for assn if.
however,the building or improvement is cold within one year of c.mpl.d.a,the owner-
builder will have the burden of proving That he did not build or improve for purpose of
sales).
E)I.as owner of the property,am exclusively contracting with licensed convectoms no
contract the pmjcU(Sec.7044.Business and Professions Code:)The Contractori U.
cense law does not apply in an owner of property who Wilds or improves Items,and
who contracts for such projects with a condacmr(s)licensed pursuant is Ne Contractor's
Lkenu Law.
❑laemmp er Sum. .B&PCfo Nis reason
Owner / V` 1 Dau /av e
mSCOENSATION DEC��ARAT��I0
1 herchy affirm under penalty of perjury one of��LNChaaK�ng deelartniors:
1 have and will maintain a Certificate of Consent o stif-usum for Worker's Compen-
1c,
lon.as provided for by Section 37M or the Labor Code,for true parfosmce of the
rk for which this permit is issued.
I have and will maintain Workers Compensation Insurerx,m enquired by Section
OOaf the Labor Cade,for IW performanec o!tits work ror which Nis permit is issued.
y Workers Campsnauion Imumnm carrier end Policy number am:
rtier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssection Iced not W completed lithe permit Isforonehuntlend dollars(SIM)
or less.)
1 certify star In the performance of the work for which this permit is issued,)shall not
employ any person in any mare erso as to become subject to the Workers'Compensation .
Laws of Calik mia.Dano
Applicant
NOTICE TO APPLICANT:If,after making this CaniOmte of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code.you must
O forthwith comply with such provisions or Nis permit shall be deemed revoked.
'Z^' CONSTRUCTION LENDING AGENCY
[—i npn+ Ihereby affirm that there I..comtmaina lending agency for the performmm of
CYi the work fur which this permit Is issued(San.3097.Civ.C.)
4 Q Lender's Name
U Z Leaders Address
V Q I certify that 1 have mad this application and slow Nen the above information is
D. F correct.I agree N comply with all city and county ordinances and stale laws reading to
pU building construction,and hereby sutharim representatives or this city to enter upon the
abovmmennioned property for inspection purposes.
(We)egme to save,indemnify and keep harmless Ne City of Cupertino against
i fA
liabilities.judgments,eats and expenses which may in any way accrue against mid City /
U Z in wnaequcne.of the grunting of this permit 1/
APPLIC NT, NDERSTANDS AND WILL COMPLY WITH ALL NON-P INT Issued by: Date
R CATIONS.
G Re-roofs
gneturcof AppIm.sa/Contract Dale
HAZARDOUS MATERIALS DISCLOSU Type Of Roof
Will the applicant or future building occupant stare at handle hammous material
a derined by the Cupemno Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicst or future building occupant tau equipment ac devices which P g
mit hampicaus air contaminants m defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes SN.
I have mad!the hocardousmverialsrcquimmen.underChapan6.95of the Caliper.
nia Health&SafetyCode,Sections 25505,25533 and25534.1 understand thaif tips building
Jars not c�;l ho P
Nat it is my mspomihility m notify the ancupant of Judoesarch riortaimy..ofa Certige ad]Ocaexce.inDBIe
Signature of Applicantown ar ,<d All roof coverings to be Class"B"or better
CITY OF CUPERTINO
ti TEMP POWER
UPERTINO PERMIT APPLICATION FORM
APN# 3 Z 6,- Date:
Building Address:
-, z 3 3 3S et/Pticd G L✓
Owner's Name: Phone #:
LiaC lq.c/C 4a—i cA6 6602
Contractor: Phone- License#:
.v 4 -�28 -I 9 Z.
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑ 42
Job Description:
Residential ❑ Comme ial ❑ 'C�b
Cost of Project:
J � <
i
y i
cable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING