03090140 eCITY OF CUPEWI'INO s.3§8 a^tz+cxk is as sswh s,: "q" ia'
BUILDING DIVISION PERMIT 4�60NTRACTnRrINFORMATION
BUILDING ADDRESS: CIVITAF CORP PERMITNO03090140
OWNER'S NAME: PERMIT ISSUE DATE '
270 E MAIN STREET
NE: SANITARY NO. CONTROL NO.
(408) 399-4949
ARCHITECSYENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
C�
lad LICENSED CONTRACTORS
oECons of CON lob Description
I ion? affirm that I am Iittnxtl udder provisions of Chapter 9(commencing ® s`
with Section]IX10)of Division 3 of the eusittess antl Professions Co@.and my liamr is �'�^�`®
inrwlmnza c cc TEMP POWER POLE ,v !s
Licenael Lie.. 2 4 2003
e{{{{---- Date Conor
G A CHITECrS DCLARATION SEP
L a 1 undeulanJ my plensshall I usedE
as public records
cap
eat Licensed Professional . BUILDING
,5 atIam OWNER-BUILDER DECLARATION C<f hereby,(Tem that 11. aempd from IW Contractor's License Anyc Law font
C20 following teaxa Permian]8nstr Business and improve.
de ms Code:Any city at county
m which nits isad n permit ata quires the
alar,impmw,demolish,or repair ed statement
.iythat
that hepnor itscensdce,aaorequios thovisiosof for such Contrarmi0Lrile aicense Law(Chapter
cep (commencing it puniuso7 the of Division
ivision of tCo ustneaind Professions
Cade)or Sq.Ft. Floor Area Va1u81100 -
2� (eat he is(commencing therefrom
7(offno the
Division3 the al aged exempt on,Any
vi loll r
that he is exempt Bcufrom and the basis for the alleged exemption.Any violullon of 36603061 . 00
Section 7031.5 by any applicant for a permit subjects the applicancao a civil Penally of APN Number _ .__ Occupancy Type _
not more man moB).
e hundred doll..PSsP ane Y YP -----
❑1,as owner or the property,or my employcm with wages as their to compedutims.
will do the work and the structure is not intended or offered for ale(Sec.7044,Business
and Pmressiom Cade:The Coruscate,License Law aces nor apply ro an he,of Required Ins ections
property who build&or improves thereon,and who does such work himselfor through his 304 - ROUGH ELECTRICAL
own employees,provided that such improvements am not intended or offered for ale.IL
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not Wild or improve fur purpose of
sale.).
1,as comer of me property,am exclusively chronicling with li¢nxtl mnu¢mu w - --
conamcl the project(Sec.7044,Business and Rafesicirs Code:)The Contractor's Li.
cease Paw does hot pply w an owner of property who Wild.or improve Behind,and
who contracts for such projects with a condrxwr(s)licensed p000llod to the Contractor's
License Lew.
❑I am exempt under See, ,B ds P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury ane of the following declarations:
I haw and will maintain a Cenifcke of Coolant o xl(4nsaat for Wmkees Chmper- _
&ation,az provided for by Section 3700 of the labor Code,for the Performance of the _
work for which this pctmit is iaued. - -
❑1 ban and will maintain Workers Compensation Insurance,az required by Section
3700 of he labor Code.for Be performance or the work for which this permit is Issued.
My Workers Compensation Insuranttc ler and Policy number art: O
Confer p.Fuv��. Policy Na,
CERTIFI \TE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the Permit is for one hundred dollars(51010)
of less.)
1 ccnify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner anus In become subject o the Workers Compemation .
Laws of California.Dau
Applicmt
NOTICE TO APPLICANT:If,after making this Ccnifinu of Exmmian.You should .
become object w the Workeh Compensation pha ildmu of the faWr Cank,you most
� ,Z forthwith comply with such provisions or this perm it hall be deemed remold -
ti O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency l'or the Performance or -
xr�i the work for which this permit is issued(Sec.7097,Civ.C.)
4 QLender's Name
1 Lender's Address
Z
Q 1 ccnify that I ban read this application and&tau that Be aWw information is
correct.l agree to comply with all city and county uNinances and sura laws misting to
'U building construction,and hereby authore opmxnutives of this city to enter upon the
L4 above-mentioned property for insrction purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
ti f0.'jl Ii ahllidies,j udgmcnts,costs and expenses which may in any way accrue against said City
JZ in consequence or the flooding of this Permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE REGULATION
Re-roofs
Si eco ApplirIHAZAR O D&u
J HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF / Q
Will the applimm or future building occupant stop m handle NvudousdmaterialSafety
ty
az ticEncd M1y the Cupenlnn Municipal Cotler Chepur 9.12,and the Health and Safely
Cndn,smetmn zss3zcarr All roofs shall be inspe ted prior to an roofing material being Installed.
❑Yrs [D No P P Y g g
Will the applicant of future building=upanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it reverends air contaminants as defined by the Bay Area Air Quality Management
vict7 all new materials for inspection.
1req
❑Yes ❑No
I have mad the husartlous materials hiquiromcnts underCm,ucr6.95 hf the Califnr-
Health sc Safety Code,sections 25505,25533 and 25534.1 understood that if the Wilding
s nod cunendy haw a tenant,Nat it is my respon&ihility w nodl'y dbe p upmt hf the
uimments
which must be mei portraitinumce of a Certificate ofOccupancy. Signature Of Applicant Date
7
er n,aa Dam All roof coverings to be Class "B"or better
Y OF
,(70
CIT EMP POW RINO
UPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address: I183-7 UrLAKD WANE, CUPW-TINIO CA
Owner's Name: CWU14E1- k SUL(rQ Phone#<<{o$
Contractor: G(VITAF CoP•P Phone: X3);19 01 License #: giRc)
Contact: D DSO U Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description: sf N<-rLT= FAMLY HoNIE
Residential Commercial ❑
Cost of Project: 300 0„0
�29
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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