04050135F CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDINGADDRESS:
WILLIAM NANCE
PERMITN.04050135
OWNER'S NAME:
PERMIT MUE DATE
WILLIAM NAN E
ONE:
SANITARY NO. CONTROL NO.
-
ARCHITEC IENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONfRAC10R'S DECLARATION
Job Description
1 hereby affirm Nat 1 am licensed under provisions of Chapter 9 (commencing
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7IXX S of the Bosinassand Professions Code,and my license is
withll
to=cdon
effect.
immBmrwand crcecfLin.
TEMP POWER POWER
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License Class
Date Contractor
ARCHITECTS DECLARATION
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I understand my plans shall he used a public records
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Licensed Professional
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OWNER -BUILDER DECLARATION
1 .mere License Law for the
1 em exempt Imre the Commlcmdon,
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fallowing mason Permian 8onstr B. aineas and w. der oil Code: Any city or county
which requires permit re err s plus Improve, demolish, 11 repsig any
y � y
stere ,
issuance, the cm
of the ConOacwr's License law (ChapterY
Mat hpoor e s Bened ..L to he the inions o for such Contractor's Uems Law (Chapter
he is liccnsedpuduam to ire
Sq. Ft. Floor Area Valuation
x<Nat
ad
pu pmvisiam
(commencing with Section 7") of Division 3 of Ne Business and Professions Code)or
i $
Nn M is exempt Merriman and the breis for Ne alleged exemption. My violation of
Section 7031,5 by any applicant for a permit subjects Ne applicant to a civil penalty of
3 AABID UIti iTberO 0
Occupancy
P Y Type
not mom Nan five hundred deltas ($500h
❑ 1, as owner ofthe property, or my employees with wages as their sole compensation,
will da thewark, and the swctum isnotimanded woffered forsale (See.7044, Business
Required Inspections
and Professions Code: The Comrsctor's License Law does not apply to an owner of
progeny who bu ilda or improves Nemon, and who docs such work himwl f ar through his
own employees. provided ehatsuch imprevements me not Intended muttered formic. If,
however, Ne building m improvement is sold within one year of completion, the owner
builder will have Me burden of proving that ke did not build or improve for purpose of
sale.).
'
❑ 1, as owner of the prapeny, am exclusively contracting with licensed comosson In
,
construct the project (Sec. 7044, Business and Professions Code:) The Connannr's Li.
came Law does not apply to an owner of property who builds or improves themon, and,
who contemn for such projects wit a canuacmr(s) licensed pursuant to the Camractur's
rise Law.
em uempt under Sem. PCfthi 00
D
er D —
WORKER'S COMPENSATIONDECLA N
1 herchy, of inn under penalty of perjury one of dte fel owing declarafom:
1 -and will maintain a Certificate of Consent to mlf insum far. Worker's Comprm
,.tion. as provided for by Section 37M of the labor Code, for Ne performance of Ne
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Wurance, as required by Section
3700 of the labor Code, for the performance of the work for which this permit is issued.
My Worker's Campensadon Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(rdsmeth n need notimcompleted if the Permit is for one hundred dollars ($100)
or leu.)
1 certify Nat in the performance of Ne work for which this permit is issued, l shall not
employ any person in any manner so as m became subject to the Worked Compensation
Laws of Califamia. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Cmnif m, of Exemption, you should
become subject to Ne Worker's Compensation previsions of the Labor Cede, you must
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forthwith comply with such provisions or this Permit shall be deemed rooked.
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CONSTRUCTION LENDING AGENCY
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l hereby aRrm Net Mo. is a construction lendingagency for the performance or
for is issued 3097, Civ. C.)
Fa >
Me work which thin permit (Sec.
Lemi.e. Name
Q
Lmdeh Addsmo
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I certify Nat I haw read this appli.d.a m4 stns, Nat the aWvc infutmadun is
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correct. 1 agree to comply with all city and county ordinances and state laws relating to
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building convection, and hereby auNonre reprmenuthres of this city to enter upon Ne
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above-mentioned property for impaction purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. judgments, coats and expend which may in any way acerae against mid City
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of the of this
fAnPPLICAcNT
rZ.s
UNDERSTANDSranting
AND WILL COMPLY WITH ALL NOWPOINT
Issued by: Date
SO RCE REGUL ONS.
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Re -roofs
Ignaturs, o(Applicant/Contmctor te
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will he applicant or future building ec"pantatorc or handle harardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
de, soden 2ss32(g7
Ym I No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant ar f lure building occupant use equipment or devices which
mit hazardous air contaminants as defined by Ne Bay Area Air Quality Management
all new materials for inspection.
District
❑Yes No
rda sm
I he. mad the ha,aterialerequimmeW under Chapter6.95 of Ns, Califor.
ria Hs,olth A Safety Cede, Sectima n505. 25533 and 26534.1 understand thmifthe building
does not curentiy haw a bounk Nat It is my responsibility to notify the occupant of Mc
rcyuirFmmme which munxmn pnarmissaanmeoracrSp�ol'�3Capen�cy.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
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Owncru uthorizcJ agent part
%CITY 0
CUPEkTINO
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Buildi
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Department
JOB ADDRESS- �p PERMIT #
T(15927.17 Ave 1, 0110-60/3S
I OWNER'S NAMEV-t✓il I;� �q , C � }PHONE # j'9� 358
GENERAL CONTRACTOR: FAX # 1711—Zy�9
I am not using any subcontractors:
Signature
Please check applicable subcontractors and comolete the following infnrmatinn-
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Date
10/28/03
Date
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
Tile
10/28/03
Date
I I Sev
CITY OF
UPERTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
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Temporary Power
ELECTRICAL
Building Address:
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BUSLIC
0
BUILDING
Owner's Name:
Phone #:
Wdlfamac
e
OS- 3 588
Contractor: 0
O�A
Phone:
License #:
Contact:
Phone:
Sy'S-35��
Cupertino Business License #:
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Building Permit Info:
Elect
Job Description:
Residential
Commercial ❑
Cost of Project:
A�t.i
hatt Fee ID
Fee Deacrintinn
Fee (rnnn
BTEMP
Temporary Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
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