06020114 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT .0aCN�.Cv k�s kw%tt• 0`s Rset i1NV*�. MAT` IFO�t N
BUILDING ADDRESS: KELLY GORDON DEVELOPMENT URF NOO6020114
•21190 CANYON OAK WAY
OWNER'S NAME: I PERMIT ISSUE DATE
Ah KELLY GORDON DEVELOPMENT 12241 SARATOGA - SMYVAL RD 02/21/2006
ONE: SANITARY NO. CONTROL NO.
(408) 873-8774
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sop
LICENSED I am CONTRACTOR'S DECLARATION
of CON Job Description
Y
I hereby affirm Net 1 am licensedBu under provisions of Chapter 9(commencing p
n� with Smresandgfof ecDivision 3ofthc Budrcss and Profesuom Code.and mylicenuts
L eneCla.ndeffect. TEMP POWER POLE
Dan Class Lm.s
a� Dam ConituCL {�rr��{� /�
R y p ARCHITECTS DECLARATION Il--{7(.\ Qp pry
1 understand m lam shell W used u public records (Cdj"'ltlj 1{6j�7p�.S(r}�'!�[�!
vtl
ssed Licensed Professional
y Oat I am exempt
from
DECLARATION
CO f following naso .(firm on I e1.exempt from Ne Comas Cc License Law for the �Z— Lt3t b
OG which requires
permit
7R3L5,Business and Profession Ca de:Any city or county
$� which sets Issuance,
sunpermit recnnWCLpWc.Improve,h permits larrepair anynnmure 200
Ny Odor hsitsiensedp also requires thovisiosofcant for suchpcmitm0ense La ed statemenChapters
�<
Oat boia licensed pursue.to the provisions of the Contractor's License law(ChaOter9 Sq.Ft.Floor Area ! Valuation •"vi'r'�
�Q b, mmcMing with Section 7000)of Division 3 of the Business and Professions Caulk)or _ {LL % A'f( I"' \tJ
� N
.. et he Is mempt thortfrum and the buts for the alleged exemption.Any violation of [1--/�II
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penally of 3U UOccupancy Type
ant tome Nan five hundred dollars(S500L
❑1,as;mw of the property.or my employees with wages as their ole compensation,
will do the work and duawcmm u not intended or offered far sale(Sec.7044,Business
and Plateau..Code:Tim Canuurora License taw don wt apply to an mums of Required Inspections
property who bai Ida or im proves Woman.and who does such work himself or Omugh his
own employees,provided that such Improvements vent intended oroRe ed for sets.If.
hansom,We building or improvement is mid within am you of completion,Ne owner.
Wilder MR have the WNen of proving WI W did law Wild or improve for purpose of
mina).
.p awmr of the property,am.elusively contracting with licensed contractors m
.tout the project(Sec.704W.Business;and Professes.Code:)The Cowumrs U.
came taw does not apply m an owner of property who Wilds or Improv Rome.and
who convects for such projects with s eomrumr(s)licensed Putnam to the Contractor's
Lice.e Law.
❑lune p"oder see. .B&PCf Nis n
/ �
Owner Dam � f g
PORKERS COMPENSATION OEC RATION
1 em y be under penalty of perjury am of the following declarations:
INE 1 have and will maintain AC,dr..M afConert io ul6inum fm Workers Compeo-
sW on,an provided fm by Section 3700 of the Labor Code,fm the performance of the
work for which this permit is immd.
❑1 have and will maintain Workers Compensation Insurance,u required by Section
3700 of the Lab.Code,for We performance of the work for which this permit is Wood.
My Worker.Campensa on Insurance eerier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thasectim teed notbocempleted if tie permit is(mane hundraddollars($100)
or 1'.)
I artily that in We performance of the work for which this permit is issued,l Nall not
employ any person In any manner e subject m We Worken'Compeneadon
Laws of Calif 2� .m tm0 f_
Applicant — �---�•
NOTICE TO APK4eANr.If.alter matins this Certificate of Exemption,you should
Wcome subject to the Worker's Compensation provisions of the labor Code,you must
.J Q forthwith comply with such previsions or this Oermft shall W deemed revoked,
z CONSTRUCTION LENDING AGENCY
E4 I hereby affirm that them its co.Melion lending agency far the perfurmame of
r: the work for which this permit is issued(Sec.3D97,Civ.C.)
Q Landers Namm
Z) z Lenders Address _
U0 l cenffy that l have mad Ran application and sou that the above information is
D, P Corea I gree m comply with all city and county ordinances nd sane laws musing to
O U building convection,and hereby authorise mpssentetim of this city in enter upon the
LTl ahovomsntioned property for Impaction purposes.
0. (we)ague to ave,indemnify and keP harmless the City of Cupenmo again
h Iiabili0es,judgments.costs and expenses which may in any way seems,age lmtsaid City
C.)z Inconsequence of On swung of this permit. �7
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date G 2( -
SOUR 0�c.
�e/_ Re-roofs
$I 0 A anUL'OnVacmr ADM
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding mcupanutore mhandic houdats material
u MBned by the Cupenfno Municipal Code.Chapter 9.13,and the Health and Safely
❑Ym
.Section ss532.1, 11 A32!7D All roofs shall be inspected prior to any roofing material being installed.
7DishWill the applicant or furore building aceupant use equipment or dcvicm which If a roof is installed without first obtaining an inspection,I agree to remove
icL?
it havardous air mmaminanu u defined by the Bay Area Air Quality Mangsment all new materials for inspection.
❑Yes '59!1-1
1 have mad the hazardous materials requirements under Chapter 6.95 of the Celifor.
e Hmlth&Safety Cade,Sections 255)5,35533 and 25534.1 unakr mad this lf0e Wilding
rs amanthatit u my mpo.ibillty m wtify to occupant.the
y ..slats whit use Wmerpdorw tssuaneeof.Ccru0cateof Occupancy' Signature Of Applicant Date
Zf All roof coverings to be Class"B"or better
Ow set Drive gent Dam
Community Development
10300 Torre Avenue
f4. 1 40 Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
INUPEkTINO
Building Department
JOB ADDRESS:2( (j o n ueN oQ� W� PERMIO KO Zai / y
OWNER'S NAME: Cc>o.9o" Vg,. Q wt PHONE # !9 -? 3 $ 7?
GENERAL CONTRACTOR aicv[ FAX # S ? 3 $d r
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
[ � 2/Z/ o w
Owne /Contractor Signature Date
CITY OF CUP ERTINO
Q. TEMP POWER
�CUPER,TiNO PERMIT APPLICATION FORM
APN# 3 tP' 2 Z_ Date: 2 6L
I 1.
Building Address: Z 90
Owner' Name: Phone#:
2.(� �ja-✓S7or� � 2J�- �✓`� �8 g73 577 .
Contr or: _ hone: '?? 077.
License#:
o
ContacL Phone: Cupertino Business License#:
Building Permit Info: r S : `j'e K Po (�
Elect V I I
Job Description: e ,
Residential �D IlJ Commercial ❑
Cost of Pro'e t:
2oa .
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING