05030327 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ° CONTRACTOR INFORMATION '`
BUILDING ADDRESS: PERMITNO.
DWK CONSTRUCTION 05030327
OWNER'S NAM 914 PERMIT ISSUE DATE
In '
,ONE: SANITARY O. OL NO.
ARCHITECfyENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+fir O o LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 hereby affnn Net I am li¢nud under provisions of Chnpmr 9(commencing
b with Second]gg)of Division 3 of NC Business and Professions Code.and my]iee.is
^�„ in full farm a ad effect.
pa�? license amu Lic.N � bZ - TEMPORARY POWER
1 Dam - OS TS-Contractor DEL 'DLII
ARCHITECTS DECLARATION
? I understand my plans shall W used as =
public eoads
U
G Licensed Pmftessio ed
3 OWNER-BUILDER DECLARATION
I hereby affim thin 1 ram exempt fru.On,Contractors License Law far the
3'.00 following mason.(section'on 1.5,Busineu and Professions Cote:Any city of county
$ which=quires a permit to convect,alter,improve,demolish,or repair any dracmm
prior in its issuance,also requires the applicant for such permit to f In a signed sta¢ment
that he is licensed pursuant o On provisions of the Contractor's Ummc Law(Chapter 9 Sq. Ft.Floor Area Valuation
anH (commencing with Section 7")of Division 3 of the Business and Professions Code)or
we
3$ Nat he is exempt therefrom and the hull for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 3.f I erO 0 _ Occupancy Type
not mart than Ove hundred doBars($50)).
El
I,ax ownu of the pmputy,or mY employees with wages u their tole compenutlon,
will do On work.and don suuctu=is not intended or.Rued for aa]c(Sec.106x,Business
and Professions Cade:The Contractor's License law dais not apply to an owner of Required Inspections
property who builds or improves drereon,and who doessuch work himself or through his
own employ=,provided Nat such improsammu arc notimanded or offered for We.If.
however,Ne building or improvement is sold within one year pf completion,Ne.vena,.
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale.).
I,as owner of the pmpcny.am exclusively contracting with licensed Contractors to
construct the project(Sec.704,4.Business and Pmfoadou Code:)The Contractor's Li
acme law docs not apply to an owner of progeny,who Wilds or improvss the=on.and
who mnuacu for such pm$cm with a combactor(s)]banned pursuant in the Contractors
Lkc=Law.
I am exempt under Sec. ,B&P C fu this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Family of perjury am of Ne following declarations:
i� I hive and will maintain a Ccnificum of Consent to tuff-insumfor Worker's Compcn-
cation,as provided far by Section 3100 of the LaWr Code.far the peAonnaece of the
work for which this permit is issmd.
❑1 have and will maintain Worker's Compensation Logone,u.quired by Section
3100 of the labor Code,for On performance of the work for which this Permit is issued.
My Workers Compout.m.Ir. e.canner and Policy number arc:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thusection need not W completed if the permit is foram hundred dollars(SIM)
tee Mss)
I cenify Nat in the Performance of/M yyrk for which this Permit fs issued.I shall not
employany person in any musl3f a bject to the Workeri compcuaoon
Iawshf Califomia.Date II"''���7lllll /
Applicant , �r-f:l?�
NOTICE TO APPLICANT:If,after making Nis Certificate of Exemptiol4ou should
become subject in Ne Workch Cumpcvutian pmvisiom of the labhr Code,you mtw
.,O forthwith Comply with inch provisions or this Permit shall be deemed revoked.
Z"-' CONSTRUCTION LENDING AGENCY
[-tom IW=hy affirm Nat there is a construction lending agency for the performance of
CLthe work far which On lannit u issued(Sec.3099,Co.C.)
W ALender's Name
64 Lender's Add=is
oz
V C) 1 cenify Nat 1 have read this applindma and sure that the aWve infmmatiun is
W F correct.1 agree to comply with all city and county ordinances and sok laws=rating to
0U Wilding convection,and hereby aumorim repacscnutiat of Nis city to enter upon the
W ahovcmcntiuned literary for impaction purfwtus.
(We)ag=e to save,indemnify and kmp harmless the City of Capetianagainst
F-' N liabilities,judgmca..Cos.and expenses which may in soy way ammo again said City -
of the oarfin,or
V z s paranit.
APPeLICANTUNDERSTANDS ArND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE EGUL ONS.
3�oS Re-roofs
Signature of ApplicanuConmctorDam
HAZARDOUS M RIALS DISCLOSURE Type of Roof
Will the applicant or future Nil.#
occupanum¢or fundic havudaus mamma]
u defrned by ore Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
code.0Y s 553z(a)9 No All roofs shall be inspected prior to any roofing material being installed.
Will Ne applicant or future Willing occupant use cyuipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havardnus air contaminanax as dc0ned by the Bay Arca Air Quality Managcmcat all new materials for inspection.
istrict?
❑Yes lsu
1 ban road the WvrNwsmamrials requiretnenu under Chapmr6.95 of the Ctlifor.
Health&Safety Code, understand!25505,25533 and29534.1 understathatifthc Wilding
es not currently have a MOM Oat it is my responsibility to notify the occupant of the
eiremrds which must W met poor to issuance of CeniEaate of Occupancy. Signature of Applicant Date
owner or aamnoxed agmr Dam All roof coverings to be Class"B"or better
Dill
CITY OF CUPERTINO
TEMP POWER
11CUPCITY OF
EkTINO PERMIT APPLICATION FORM
APN # Date:
3 S -1 g -00' 3 3l/03'
Building Address: , r
O ( t V r
Owner's Name: / / Phone #:
d02CoPX W 2 1402-
Contractor':
ntractor: U Phone: License #:
pwKCm,sfiue (om) 30 -a s g g2oo2
Contact, Phone: Cupertino_ . siness License #:
h C6 (0 30 �-
Building Permit Info:
Elect
Job Description:
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
/ EPERMITFEE 'Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING