03080003crrY or curEaartNo
BUILDING DIVISION PERMIT
CONTRACTORINFORMATION
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RU ILDING ADDRESS:
0400 TORRE AVE.
PERMIT ""03080063
O W NER'S NAME:
PERMIT ISSUE DATE
r
LIBRARY CITY"OF CUPER NO
08/01/2003
ONE:
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SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG HLECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I beseby affirm Thal I am limnmd under provisions of Chapter 9 (commencingr
x� s -v ss p e yis�y
with Section ?Ofg))of Division 3 critic Rusinessend Professions Code, and my license is
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in full farce and .(fire, Q L1cg --� �y
License
TEMP POWER POLE
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CONTRACTOR:
Date •-q� Oromelof t
ELCOR ELECTRIC AUG 2 0 ?_003
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
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Licensed PnMcuional
OWNER -BUILDER DECLARATION
BUIL7� Y'si
1 hereby affirm License Law the
11. exempt seam the Contractor's
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cos
Code:
e: A
fallowing mason. (Section ? Calc: Any city or county
maso on Business and Re.
d,an i
o str alcp rat fron, nr si(my tlmcmte
which requires a grail ac cams
h Permit t
prior msl Issuance. also n: to the thevpionsot for suchPermitfieasigned nammcm
Me e a
it licensedpuntion70hcpmvivisionfthe CommctuhndProfLaw (Chapter 9
Sq. Ft. Floor Area
Valu�{k 000
(com iwith of Division3 ofthe Cewe7 of
Business tendon.
that he It homfon?f100)
that Any of
from and the beers for the ted exemption. Any
ege
uexempt1.5
GrO0
Occupancy Type
P Y -
btante
Section for R subjects l penalty
'
not
Bol more than five hundred dollars fSS(p).,
❑I, a owner of the pmFeny, or my employees with wages As their sole compensation,
Required Inspections
will do the work. and Ne suunoa is natimanded or offered for sale (Sec. 7W, Business
Code: Contractor's Law
end Profdssion& The License dads not apply to an owner of
103 - UFER
property who build& or improves thereon, and who does such work himself or Mmugh his
own employes, provided Nat such improvements are not intended proffered for sale. If.
304 — ROUGH ELECTRICAL
however. Ne building or improvement is mid within ane year orcompledan. Ne owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
ale.).
1, ea Owner of the property, am exclusively contracting with licensed mmACLom Ins
construct the project (Sec. 7044, Business and Professions Cade:) The Contractors Li.
_ -
ecnm Law does not apply to an owner of property who Wilds or improves themon, ad,
who contracts for such projects with a contractor(&) licensed pursuant to the Contractor!
License law.
❑ I am exempt under Sec. B & P C for this sawn
Owner Data
WORKER'S COMPENSATION DECLARATION
_
I hereby affirm under penalty of perjury, one of the fallowing declarations:
I ban and will maintain a Certificate of Consent to Ulf-insum for Workers Cumpenm
on, a providedfor by Section 3?D0ofthe LAW, Code, for Ne petfmmenm of the
k for which Nis pcnnil is issued.
I ban and will maintain Workers Compensation Insurance, an required by Section
il
p of the fAhor Cale, for the performroce of the work far which Chia permit ialaued,
Workers Cam pensadon Insurance carrier and Policy number as:
Catrier:7ylt+`ct's ItY�eil1-• POLICY No.:i IU.1M T�,Liro—rDt
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CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
(TTI& mmirn recd not Iccomplival India permit is fororc hundred dollen (sl W)
nr kss)
I certify that in Ne Perfurramce of the work Tor which this permit is issued. I shall not
employ any person in any manner ep u W laccomg subject the Workers Compenatlon
Law& of Californi. Due sfa
is
Applicant T, \Paa.
NOTICE To APPLICANT: IL after making this CempeanEW Exemption, you shoulJ
become subject to the Worker's Compensation provisions of the labor Curb, you must
forthwith comply with such provisions or this permit shall be deemed ranked,
CONSTRUCTION LENDING AGENCY
'
1 hereby athrm that More its emutmctinn lending agency far the performance, or
the work fur which this permit is issued (See. 3097, Civ. C.)
1<edetf Name
-
Lcndm'sAddrea
1 cenify that 1 have rad this application and state that the above information Is
'
correct. l agree to comply with all city and county oNinence& and state laws slating to
building conumaion, and hereby authentic representatives of this city to enter upon the
above-mcmnerad property for inspenion purposes.
(We) agree to save, indemnify and keep haratims the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way same against said City
in consequence of the granting of this permit.
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APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signature of ApplicmVCanDOr Data
HAZARDOUS MATERIALS DISCLOSURE
Boom
Will the applicant or taus building occupant stoat or handl<heallous material
a defined by the Cupertino Municipal Cade. Chapter 9.12, and Ne Health and Safety
doo.Seclion 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yet 0,q -
a roof is installed without first obtaining an inspection, I agree to remove
Will
WIII the applicant or future building cecupam use equipment or devices which
it haardnus air comam nal nu a Jcfned by the Bay Arca Air Quality Management
all new materials for Inspection.
151llct? \
❑Yes j
I ban mW the haardtms materials requirements under Charier 6.95 of the Cali for.
nice Hctlth&Safely Code, Secuods 25505, 25533 and 25534.1 untlersund the if the Wilding
,
Jacor Bol camenry have a Oman4 Net it is my responsibility m nnufy Me oacupmt nr the
mquimmc to It mallbem,pdorm bounce Ora Certificate or Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner dagent
or authorfv to
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Wcin o
UPEkTINO
CITY OF CUPERTINO b 6 o-v—p3r,
TEMP POWER
PERMIT APPLICATION FORM
APN #/ )l v 3 �
Temporary Power ELECTRICAL
EPERMITFEE
Elect. Permit Issuance ELECTRICAL
Date: Q
Building Address: O j�
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wEt�e
Aue'
Owner's Name:
Phone #:
Contractor:.
8600A ;2�
Phone:
05 -9 5 to 13;P3
License #:
I
Contact nI�S(�' �R�=h}-(az
Phone:
�t� • 8 /� - i X7.0
Cupertino Business License #:
Building Permit Info:
Elect Fr
Job Description:
Residential ❑
Commercial fKJ
Cost of Project:
Qty. if
Annlinnhle Fee M
Fee Decrrintion
Fee Groun
BTEMP
Temporary Power ELECTRICAL
EPERMITFEE
Elect. Permit Issuance ELECTRICAL
BUSLIC
Business License BUILDING
a