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CITY OF CUPERTINO - - 4a4 >�, tea R
BUILDING DIVISION PERMIT CUNTRAC O ANS RMATI41 '
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BUILDwGADDRESS: ATLANTA CONSTRUCTION INC PERMIT NO 04090002
OWNER'S NAME: PERMIT IEEUBDATB.
ONE: SANITARY O. ROLNO.
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
.0 o - LICENSED CONTRACTOR'S DECLARATION
U 1 I..7 affirm Nm 1 am of the
Business
under provisions of Chapter 9(commencingsis lob Description F I NAL E
with Semon 7g1U)of Division]of me eusinrs and Profasivas Code,and my liens is
in full force and effect.
nuia:z Lieenxeclasx Lie.« TEMP POWER
NO a O Dam Com.lar
ARCHITECTS DECLARATION
�v 1 undcrsmnd my planation]he tied u public mantas
SEP V'} 900).
T
J�U VCP L
5 G t; Licensed Professional
3 Oat I am attempt
Eform We RATION BUILDING
C f I masa affirm on 1 1. acmpt from the Canine Co License Any c Law for the
i o o which ra mason.(Section 7113 LA Business and Professions rs.or Any city or county
y$ which mquires a permit m centimes¢Iter,improve.dcmnlixh,m repair any svuaum
rZe prior to its issuance,also requims the applicant for such Ismailia rile a signedsuamem
u .
�Q that he is licensed paramount the provisions of We Com=tnrs Licens Law 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7")of Division 3 of We Business and Profeuiens Code)a,
..
that he u exempt tWmfrom and the basis for the alleged aempuon.Any violadon of raeu w��'wr0.
Section 7031.5 by any applicant for a permit subjects We applicant to a civil penalty of 3�U Lf.Ip YyrsasyP,TOO Occupancy e
nal more than five hundred dollen(5300). p y Type
❑I,as mawn.f the property,or my employ.with coag.as mei,sol.compound.,
will do We work,and We svucame is not intended or offered for sale(Scor.7045,Business
and Prolamines Code:The Convectors License Law d=not apply to an owner of Required Inspections
property who builds orimprower memon,and whod.such work himselfor through his
own employ.,provided that such improvements tie not intended oraffead laterite.If.
however,We building or impeawmant is sold within one year of eampleuon.We owner-
builder will haw the burden of praying mat W did not Wild or Improve for purpose of
ah.).
❑1,as net of the property,the embedively convecting with licensed characters to
construct the project(Sec,7054.Baines and Professions Code:)The Contractor's Li.
cense law does not apply to an owner of property who Wilds or impravea Woman,and,
who contracts for such projects with a contractor(s)licensed pursuant to We Contractor's
Liters..Law.
❑1 am exempt under Sec. B d P C for this reason
Own Date
WORKER'S COMPENSATION DECLARATION
1 Wreby affirm under penalty of perjury one of the following declarations:
1 he-and will maintain a CenlftcamCo
ofnsenua sINnsum for Workers Camper-
color,as provided for by Section 37W of the labor Code.for the performance of the
work for which this Permit is issued.
❑1 have and will maintain Wmkert Compensation loseence,as required by Section
3700 of the labor Code,for the perfar comm of We work for which this parrot ie issued.
My Worker's Compensation Insur n e carrier and Policy number am:
Cartier. policy Na.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This auction mail not he completed if the Permit isfor one hundred dollars(5100)
to Its.)
1 anify mat in the Performance of We work for which this Permit is issued.I shall not
employ any Person in any mannerso as ut become subject o tW WorkesCompensation
Laws of Calif raht.Dau
Applicant
NOTICE TO APPLICANT:If,idler making this Certificate of Exemption,you should
Weems subject In the Warker's Compensation previsions of We Libor Code,you must
.JO forthwith comply with such provisions or this permit shall W deemed revoked.
,z., CONSTRUCTION LENDING AGENCY
[—� I hereby affirm that Were is a commotion lending agency for We perfurmmtt of
We work for which this permit is Wind(Sec.3097,Civ,C.)
W�Q Lender's Namc
=t Z Lenders Address
Q Q 1 anify that I have read this appilemon and sou that the be.information Is -
n, correct.I agree to comply with all city and county ordinances and state laws relating to
C) building construction,nd hereby authentic mpreaenutives of this city to enter upon the
W shove-menummd propc st fard inspection.expenses
purpose.
(We)agree to saw,indemnify and kap homeless the City of Cupertino against
y inconsegenceo diecoarsing ex pensas which they in anyway accrue against aid Cily
t,)7 A APPLICANT
of thegranting of this perm!!. ^
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature afApplieriDem
HAZARDODO US MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building e.Chapter
or handle ha'rurdous materiel
u defied by the CupeNna Municipal Cade.Gepter 9.@,and the Health and Safety
ode. f l .n zss3z(+)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea C]No
Will the applicant or future building occupant use equipment at devise which If a roof is installed without first obtaining an inspection,I agree to remove
out havardoa air contaminants as defred by We Bay Area Air Quality Management all new materials for inspection.
11C
CYou ❑No
1 have mail the weirdnessmaterials requirements under Chapter 6.95 of the Califonia HcaW&Safety Code,Sections 25505,25533 end 25535.1 unmense d that if the building
es not currently haw a tenantmat it is my responsibility m anify theoccupantof me
quirement.whichmustwmetpriannissuanceoraCenlfiateofOccupancy. Signature of Applicant Date
wner or aur tuoy.od agent DamI All roof coverings to be Class"B"or better
Community Development
10300.Torre Avenue
td
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
�UPERTINO
Buildin De artment
JOB ADDRESS: PERMIT
OWNE 'S NAME: — h —
jWp4A PHONE # 8
GENERAL CONTRACTOR: I FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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
er/ n Signature D to
ISV,
OF CUPERTINO
TEMP POWER 1
$ Y OF
CUPERTINO PERMIT APPLICATION FORM
APN# Date
L
Building Address: 8!L Cyt bL
Owner's Name: Phone #:
Contractor: \ Ph on : License #:
Contact: Phone: Cupertino Business License#:
Building Permit Info: p (�b 6
Elect ❑ /
Job Description:
Residential X] Commercial ❑
Cost of Project:
V
Qt if
ApAqable Fee ID Fee Description Fee Group
BTEMP Tem orary Power ELECTRICAL
ERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
2-