03100003 CITY OF CUPER'I'INO f'^'�s +x4Tx usn 'IF •k< y=�S "a
BUILDING DIVISION PERMIT �CONTRACTTOR INFORMATION-t,
BUILDING ADDRESS: PERMIT'003100003
OWNER'S NAME: PERMIT ISSUE DATE
POWER TV 10/01/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
I�
+Op LICENSED CONTRACTOR'S DECLARATION Job Description
E1 hereby affirm that I am licensed under provisions of Chapter 9(commencing p
with Seeti ]W,)of Divixkm3of the B inessand Professions Cede.andmylicenxis
+'1d inmufn rcea. 5-10 ' SATELLITE DISHES
)�: Liccn s Ic. .
oil Cum.emr CONTRACTOR: COITCOM SATELLITE SERVICES
pp ARCHITECTS DECLARATION
3 W< 1 understand my plans shall he used as public records
yy
cQ Licensed professional 0
OWNER-BUILDER DECLARATION
COO 1 masio .(Sec thin 1 1. exempt from the Contractor's Any C Law for the 3
pp followwhich
Permit ]onstr t,Alter. and Professions Co dc:Any carp or musty
COO
wM1ich requires a pcnnit m cnnswc,,siren,impmw,dcroslixh,or repair any ewaum
° poor o its issuance.also requires the applicant For such permit to rite a signed statement
vE< that he is licensed pursuant o the provisions of the Connector's License Law(Chapter 9 Sq. Ft. Floor Area VaIU$Lbe 000
eH (commenei ng with Section 7")of Division 3 of the B usineu and Professions Code)or
$
that he is exempt therefrom and be basis for the alleged exemption.Any violation of �n1c�_
Section 7031.3 by any applicant for a gesmh subjects the applicant to a civil penally of N4at•Uih5e OO Occupancy Type
not mom than Bn hundred delta.($500). - - - - P Y -- -
❑I,As owner of the preperty,in my employees with wages as their solo compensation,
will do the work,and the swctum is not intended or offered for sale(Sec.]044,Business gp� re
And Professions
Code:The Convector's License law does not apply to an owner of 101 - FOUND
1�N d Inspections
progeny who builds or improves themon,and who Coca such work himself or through his
awn employe",provided thu such improvements am not intended proffered for sale.If. 102 — PIERS
however.the building or improwenem is xld within one year of completion,the owner.
builder will hive the burden of proving list W did not Wild or Improve for purpose of 103 — UFER
104 - REBAR
C] 1.as owner of the property,am exclusively connecting wi th licensed contractors to lO5 — ANCHOR BOLTS
convect the project(Sec.7044,Business and Professions Code:)The Contractor's Li
Crone Law docs not apply to an owner of property who builds or improves thereon,and 106 - SEWER & WATER
who contracts for such projects with a cmaractor(s)ficenxd pursuant to the Contractor's
License Law. 202 - UNDERFLOOR PLUMBING
I am exempt under Sec. ,B&PC for this recon 203 - UNDERFLOOR MECHANICAL
owner Data 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
I hereby a(frse under penalty or perjury one of the following declarations: 205 - UNDERFLOOR INSULATION .
70371')�I)
have and will maintain A Cenifinm of Consent to self-insum for Woricea Compere 301 — ROUGH PLUMBING
n,es Provided for by section 3]00 or dm LAW,Cada,for the performancc or the � 302 TUB & OR SHOWER
k for which thispermhlaissued. 303 - ROUGH MECHANICAL
have and will maintain Worker's Compensation Insurance,as required by Scction of the Labor Code.for the performance of the work for whi thisarmitisluaed. 304 = ROUGH ELECTRICAL
Workers Compensation Insurance carrier and Policy n I: 305 FRAME
irT!'. 'tS(7o1a—o3 306 - HOEDOWNS
J CERTIFICATE OF EXEMPTION FROM WORKERS'
lnj"u lcg.COa4E ATION INSURANCE 307 — INSULATION
fro.section need not he Completed if the Permit is for one hundred Collas IS 100) 308 - SHEETROCK
or ceni.) 309 - EXTERIOR LATH
e certify that in the performance it rent f r which this pe,W is issued.I shell Mn
employ any pe,r sin nym este c o subjccn the workcn'Compensadon 310 - INTERIOR LATH
L,w, c.hmr c 311 - SCRATCH COAT
AppR
Norlc 0 LI ANT:Ir ler making Ihlt cnificale of Exemption,you should 313 - ROOF NAIL
become suhj t the Worker Compenselion provisions er the fahor Code,you mus,
z mnnwhnmm ywnhsuchprovisionsorthispermitshallhcdeemedrevoked. 501 - FINAL ELECTRICAL ENERGY
L0 CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
Ihereby affirm that there is a construction lending agency for the Performance of 503 — FINAL MECHANICAL ENERGY t
aY> four work for winch this permit is issued(sec.3047.Cir.Cd Namc 504 - FINAL BUILDING ENERGY
.7 Q- Le&,',
Z) Z L ma rnaem 505 - FINAL ELECTRICAL
p 1 certify Nat 1 haw read Nis application and rete IMI the above information is 506 - GAS TEST
j (~ crosect.1 agree to comply with all city and county ordin Tina and amm laws relating to
O Wilding convection,and hereby amhorix representatives of this city income,upon the — FIN PLUMBI G
� U aWvcmcmioned properly for inspection purposes. OS FI%WING"
L
(We)agree Io save,indemnify and keep harmless the City of Cupertino against
ti V) liabilities,judgments,costs and Capons"which may in any way scenic against said City
,Z in consequence of Ne granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: S Date
SOURC E U TIO
11 Mi —i "j-'_03 Re-roofs
Si ureofA i ardComr Data
HAZARD U
Type of Roof
Will Applicant or rule.building occipou"Imeor handle havarduus material
As defined the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Cnd0.5ccti ex 25533(e)? All roofs shall be inspected prior to an roofing material bei.
❑Yes ❑Nn p p Y g being installed.
Will the applicant or future building occupant use equipment at devices which 'If a roof is installed without first obtaining an inspection,I agree to remove
ha'sakous air commminan s As dclincd by,he Bay Area Air Quality Management all new materials for inspection. .
7i,Hcelth&S.Ie,yC�.Sw
ct7
❑Yea ❑Nu
I ban mail the MaeNnus materials requirements underCMpmr 6.95 o(thc Califer,
o.2M5.U533andM534.1 milonundthuirthe Wilding
nm cumendy haw a mmol,that iI is my responsibility m nndfy IM occupant or the
rcmenm which must he me,prior m issuance ora CadEcam of Occupancy. Signature Of Applicant Date
er ser 6
o iced agent eco All roof coverings to be Class "B" or better