04060261 CITY OF CUPERTINO _ - e * r k �• - - -
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BUILDING DIVISION PERMIT �a�z�
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t BUILDINGADDRESg: LANDMARK PROPERTIE MANAGEM] "b4060261
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OWNER'S NAME: PERMIT ISSUE DATE
LANDMARK
ONE: - SANITARY n 9 CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONnsed I CONTRACTOR'S DECLARATION
of CON
m 1 ionby affirm Nn 1 am fthe Bd under and
Prolamines
provisions nesCode. 9(commencing lob Description
with Sectlan]IXXl)nfDiviaion3ofthc BuxinmsanO Prafcesianx Code.and my license is ✓ � ,
infail force eadeffect. TEMP ELECT. OUTLET
Z License Class - Lim.
Dam.Contractor
n Q�Q ARCHITECTS DECLARATION
W u 1 understand my plana shell he used as public recordsQO�y
a V 7
3p Licensed Pmfessionel �AI�
OWNER-BUILDER except
from
DECLARATION /Y
0 1 hereby.(Rein Nat I our cxcmpt from the Connector's :License Law for the .
S e O following neuro.permit
t ]I muni Business and Professions demolish,oe:Any city ter county
k m which inquires a permit re c�res the eller.imprnvc,h permittfi repair any statement
_
H m i that hor e its issuance,edpurl also requires in the pre isionsof forsuchle a w(Chapter $200-
that -
Fzp (commencing
ince withSeauanunln)ofDiviomofoftheB rotor ulPucisw(Chepl)do Sq.Ft. Floor Area Valuation
an l- that
s...Ldoodaion mar, logo,Division n(thcBed exempton.An item Cock)ar
Net io u exempt therefrom and Ne.psis for the alleged Gumption.Any violation of
Semon 7031.5 than
wry applicant fora permit Subjects Ne effluenteffluentto a civil penalty of 3]t�IIIV ufi*e10 0
not more Nen Rhundred dollars($50M. �)GCUpanCy Typo
❑1,as owner of the property,or my employees with wages az theiramle compensation,
will do She work,and Ne swctme isnot intended ornQered forsaie(Sec.704,1,Business
and Professions Code:The Connector's License Law does not apply as an owner of Required Inspectionse(
pmpeny who builds orimproves thereonand who doessuch work himselforthrough his
mwnemployoes,provided that such improvements arc not intended oro@red forsale.if, p ,2ys ®-
however,the building or improvement is sold within one yew of complelied.the owner- MIO,D V
builder will have the burden of proving that he did not build or improve for purpose of
sate.).
1,az owner of the property,am exclusively contracting with licensed contractors In ® ��
c "n' the projen(Sec.]W4,Business and Profeseimm Code:)That Connector's Li.
came Isco does not apply to an owner of property who builds or improves thereon.and
who contracts for such projects with a cuntnewr(a)liwnwd penuam w the Conmetor's
License law.
❑l em emold ontle sec. B R P C for this noon
WOR R'S M ATION DE TION��
1 hereby affirm under penalty of perjury ow of the following declwauons:
1 have and will maintain a Certificate of Consent to self-indem for WallowsCompen-
sminn,az provided for by Section 3]00 of the letter Code,for Ne performance at the
work for which this permit is issued.
❑1 have and will mainlein Win
Compensation Imuran¢,az required by Section
3]00o(thclabor Cade,far the per(ormancc of the coo&for which Nis permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Dissection wed n ntheemmpleted IBIS,Permit is formic hundred dollars(SI W)
or lass.)
1 certify that in fie performance of dee work for which this permit is issued,l shall not
employ any person in any manner an as to become subject to the Workeri Compensution
Laws of California.Data
Applicant
NOME TO APPLICANT:If,Mar making this Cenifiam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J 0 forthwith comply with such provisions or this permit shall be decread revoked.
CONSTRUCTION LENDING AGENCY
[r 1Moody aurin Nat there is a concocted lending agency for the,performance of
C
the work for which this permit Is issued(Sec.31397,Civ.C.)
W�Q Lender's Name
z
1 LcndelAddress
V Q 1 renify Net 1 have reed Nis application and sure Nat Ne above information is
fY Hcorrect.1 agree to comply with all city and county oromances and sure laws minting to -
C V building construction,and hereby authorise representatives of this city to enter upon the
above-mentioned property for impaction purpowhich may
(Wc)agree to save,indemnify and keep hwmiess the City of Cupertino against
w rte
liabilities,otic.o thecasuantl expenses which may in any way accsue against said City
V z APPL CANTcUNthc RSTANDf t WILL COMPLY WITH ALL NON"POINT Issued by: Date
SO BGU TIONS.
� Re-roofs
Bijbitioure o(Applicant/Contrecmr ate
HAZARDO MATE SDISCLOSURE Type of Roof
Will the applicant ar future building wcapam atom or handle hammdoes material
az defined by to Cupertino Municipal Code.Chapter 9.12,pad the Health and Safety
Code,Section 25532(.)?
❑Yes >5bLp All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant one equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haeandeus air Conundrums m d Ewd by the Bay Area Air Quality Management all new materials for inspection.
District? \ p
❑Yes Milo
I have read the ludwo es materials requirements unm,Chapter 6.95ofthe Califor-
niaHcelNffiSaba yCode,Swdons 25501�3d25534.I unJcntantlthetif thebuildingJas not curtently heti a urn N ismihility mnotify dteoccupantf themquirem oat m r.CeNncateof0capwcy. Signature of Applicant Date
own tar authorised agent ,te All roof coverings to be Class "B"or better
f
CITY OF CUPERTINO
TEMP POWER �� 6 a 2
UPER`iNO PERMIT APPLICATION FORM
APN# �( / 7� v d Date:6 3G UG
Building Address:
wner's Name: / Phone#:
Co tractor: Phone: License#:
C c _
Phone-j Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description-
Residential ❑ Commercial ❑
Cost of Project:
Qt . if
A li ble Fee ID Fee Description Fee Group
BTEMP Ternporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING