05080227 CITY OF CUPERTINO 3 CONTR
BUILDING DIVISION PERMIT ACTQR MORMATIQN
BUILDING ADDRESS: ......
ERM.NO.O 5 0 9 0 2 2 7
0";60 -q TANTAII AVP
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO, CONTROL NO.
ARCHIIEC 1614CINEER: BUILDING PERMIT INFO
�PA' hY R BLDG ELECT PLUMB MECH
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� O LICENSED CONTRACTOR'S DECLARATION '"` f1rllp-
r� 1 hereby affirm Nat 1 Am liawcd under provisions of Chapter 9(commencing ob be 41180,
With Section 7M)of DNI.Ion 3af to Business and Prof shm,Code,and my license is a
Int°°f°rt`°"°`fuse TEMP POWER POLE s'GP
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License am L'r.• ssoo�
L Dalc ConuvL
lar
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ARCHITECTS DECLARATION
y I understand my plans NN be used As public mex rds g}�y{jf
7 �Q F1jc ft�
yFa Licensed Professional �FJ (�(;J��fl
33 OWNER-BUILDER DECLARATIONVfI \\V�
+�<2 1 hereby aRrm that I am exempt fmm the CAnuactars License Law far the
3:00 following mason.(Section 7031.5,Business and Professions Cade:Any city or county
.110! which requires a permit th comment alter.Improv,demolish,or repair any urwtum $340
prior to its issuance,Mm requires the applicant for uch permit to file a signed statement
zFp< that Ise is licensed pursuant to the provisions of Use,Comeacum's Licurrom LAW(CIMPUx 9 Sq.Ft.Floor Area Valuation
d$ (commencing with Section 7000)of Division 3 At the Business and Professions Code)or
thu -
3 hme 6 rapt Nmfrm
ecand the basis for the alleged exemption.Any viohdon of
Section 70313 by any applicant for a permit subjeeu the applicant r a civil penalty of
not mom an fin hundred dollen(SSW). er Occupancy Type
N
O I,an owner of the property,a my employees with wages As the4 sole compemNw, -
willdeuheAM&And the structure 6 wt intended or offered per we(sec.7044,Busiwu Required Inspections
and Professions Code:The Comrvlora License,Law does not apply w an owner of e q P
property who builds Or improves tweet,and who does such wale hireaelf w through his
Avon employees,provided the such Improvements are not intended or offered for We,if,
however,the building or Improvement is sold within sou lass of completion,the owner.
builder will haw the burden of proving that W did but tosild or Improve for purpose of
sale.).
O 1,As awwr of the Property.am exclusively cor u cling with licensed conm.ctou to
consumer the project(Sec.7014,Business and Profession Code:)The Conmu7au"U.
cause law does not apply m an owner of property Who builds or improves themon,and,
who contracts for such projects with a conuactor(s)cawed pumas m the Commentei
Lice.law.
❑lame in noer See. ,Bk PCfo thls n
Ow D.¢ ; a+Y
ER OMPEN ATION DECLARATION
1 hereby afn m under Penury of perjury,arc of the following dwlsratiom:
I tun and will maintain a Certificate of Consent lo self-lmum for WoMeesCompen-
ton,u provided fw by Sactian 3700 of the labor Cade,fes the performance of do
work for which this permit is issued.
❑I haw and will maintain Workers Compenallon Insurance,u required by Section
37W of the labor Code,far the performance of the work for which this permit is Issued.
My Workers Compensation Insanna carrier and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Tito Auction wed not be completed Ifthe Mrmil Is Intern hundred dollen($1 0111)
w leu)
1 unify that in the performance of the work for which this permit Is issued,I shall not
gmplyr.mwny mamtersoumbewme mbjeo[la ml�+W pemati°nn.'ND If.after makes this CertiOcate W Exempfian,you should
WorMeS Compensation Provisions Af due Labor Code,you muss
.J Q forthwith comply with such provisions or this permit shall M canted mwRed.
.Ea 5; CONSTRUCTION LENDING AGENCY
ti
[—m hereby which res thus Verttosued(Swtinnlending agency for the performance of
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the wurk for which this permit 6 issued(Sec.XN'l,Civ.CI
Lendersm
Nu
z
7 z Lender's Address
U C I certify that I haw read this app kstion and MAN that the above information is
correct.I agree to comply with all city and county ordinances and sate tows mlating u
Q SV-: building consWeti°n,and hereby authadm representatives of this city m scow upon the
W show-mentioned properly for impecii°n purposes
gy (We)agree to um,indemnify and kap hartev the City of Cupertino almost
hr(A liabilities,Judgments,costs and expenses which may in any way scome Against said City �^
in
uAme,or the
of
V APPLE NT UNDERSTANDS ANDWILLWILL COMPLY WITH ALL NO -POINT Issued by: Date
SO EGULATION
1� IssRe-roofs
S i2�id FuIrpp las h150Aown ar Due
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future building occupant nom orhandle hvardom material
As defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.s 3 Yes ❑Nu
e25532(4)?x(.)7
❑ All roofs shall be inspected prior to any roofing material being installed.
WIII the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it WrArdous air contaminants u dcOwd by the Bay Area Air.Quality Management all new materials for inspection.
suitt7
❑Yee [:1 No li
I hawmW the haurdws materials requirements under Chapter 6.95 of the Califon
oleBeat aSafely Codc,Scctmu 25505.25533 and 25534.1 understand LOU ifthe building
dos not cu rely haw a tenant.the It I.my rwponst.ably m nobly the acupsut of the
Mqu' n which muss be me pdoru its aof•Cenificam of cy. Signature of Applicant Dale
or z L All roof coverings to be Class"B"or better
w sada Dam
Community Development
10300 Torre Avenue
aClOF
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
UPEI�TINO
Buildin De artment
JOB ADDRESS: PERMIT # 0 ds0_ O 2'2.
OWNER'S NAME: PHONE # "C.v
GENERAL CONTRACTOR: 1 FAX #
I am not using any subcontractors:V/ Pu Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
' Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
jAT' eer/Contract r Signature Date
CITY OF CUPERTINO
I amt-1- TEMP POWER >
UPEkTINO PERMIT APPLICATION FORM
APN# 3 -7s
. Date: ,
�S,37-o i
Buildin7Q Address:
Owner's e: Phone#:
Contractor• Phone: License#:
i7A $ /tel Grp
Contact: �y� Phone: Cupertino Business License#:
Building
Permit Info:
Elect
Job Description:
Residential ®- — Commercial ❑
Cost Projec �y
U
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
'17