03110080 (2) /) CITY OF CUPERTINOk= OR
BUILDING DIVISION PERMIT �C�ONTRACTbA INFMAT ``.
ION
-. ..p
BUILDING ADDRESS: CHARVEZ CONSTRUCTION PERMIT NOO 3110080
7743 CARRIAGE
OWNER'S NAME: PERMITISSUEDATE
SREEPATHY 360 W 8TH ST 11/17/2003
NE: SANITARY NO. CONTROL NO.
(408) 893-7693
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
iooLICENSED CONTRACTOR' escr
S DECLARATION lob Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
.Z, with Sec on W0)uf Division 3 ol'0 Bus' sand Professions Code.and my license is
infu111. adeffen. /6�7>�J TEMP POWER POLE
License Lie.«
Dau / /'7 Imes r L
`3 N ARCHITECT LARATION
C 1 unee ,,y plane s be use as public accords
e01 Licensed Professional
7 g OWNER-BUILDER DE A0.ATION
2 a 1 hereby,('firm on I I exempt from Nc Contractor's Professions
oLicense Law for the /
p O following mason,(Section 703 IS,Busher, and Professions Code:Any tiny or county /
5$ which requires;a permit reconstruct,applicant
improve,h Permit
t o,repair any structure CJ O
Prior to its issmnmd It....at 1.the
the applicant for mehpclth's fdeae Law(Chned aim,9
E < (commment
that he encing ithSection7 h)ofDivions Of th.sion3rtheBsinssanccnulaw(Code)or Sq.Ft. Floor Area Valera O
c+ 0 (cat he is
(commencing Section and of basis
3 the
al Business ess and Proon.Any
ladon of
� $
that he is exempt therefrom and the buil far the altcgcd exemption.Any vlobnion of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penally of 3�AP&4?gWe—,rn Occupancy Type
not mom than Eve hundred d.11ara(5500).
❑1,u owner of the pmpeny,m my employces with wages u their Bole compensation,
will do the wmia end theatruoure is non intended moflimed f...1.(Sec.70M,Business
and Prefectures Code:The Contractor's License Law data not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himselfor through his
own employees,provided that such improvements an,not intended.Tottered for tile.IL
however.the building or improvement is sold within one year of completion.the owner.
builder will prove eo burden of proving that he did not Wild or impm m for purpose of
sate.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Seo.7014,Business and Profession Code:)The Contrsemrs Li.,
cave law does not apply to an owner of property,who Wilda or improve tWuon,and
who contracts for such projects with a comsat car(,)licensed pursuant no the Contractor's
Liccnu Law.
I am exempt under Sec. .B k P C for this moon
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following dedantions:
I haw and will maintain a Certificate ofComenuo sett iasure for Worker's Compee-
7031(W'
on,a provided for by Section 37M of the labor Code.for the Performance of the
rk for which this permit is issued.
1 Mw and will maintain Workers Compensation Insurance,u myuined by Section
of the tabor Codc,for Ne performance of the work for which Nis permit is luded.
Workers Compensation Insnaunnma caner an'd,Policy number art:
✓�f/dl# AOF XF
VVV
CERTIFICATEOMPE SATIONIONFRAN WORKERS'
COMPENSATION INSURANCE
(this section need not be mnapumd little permit mforone hundred dollars($100)
or pus.)
I certify that in Ne performance of she work for which this Permit is issued,I shall Out
employ any person in any manner u as as become subject to the Workeri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this CeniRcau of Exemption,you should
become subject to the Worker's Compevalion provisions of Ne Labor Code,you mull
.'O forthwith comply with each provisions or this Permit shall be deemed resmked.
M CONSTRUCTION LENDING AGENCY
I beuby,Brat
that Nem is a construction lending agency int the performanceor .
fL ti the work fur which this permit is issued(Sec.3097,Cih,C.)
Lo Q Lancers Name
z lenders Add.
U Q 1 cenify that I have read Nis application and some that the aWw information It
I5.F comm.I agree to comply with all tiny and county ordinances and stilt laws Mating In
pU building conswnion,and hemby..derine uprcaemtiws.f this city an enol upon the
rw aWvomambrued properly,for inspection purpose.
(We)agora to ave,indemnify and keep humless the City or Cupertino against
liabilities Judgments,cols and expenses which may in any way accrue against mid City 1�
C)zs Permit.
APPLICC NTeof me granting of UNDERSTANDS AIND WILL COMPLY lW2tLAJrI.NON-POINT Issued by: Date V
SOURCE g�ULATIONS lJ
A� /`J'I/'J' Re-roofs
$ignuure of Applicant Contractor "I Data
S�Vf HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant.future Wilding.ccdpant su re.,handle harardua maunid
at deflood by the Cupertino Municipal Code,Chapter 9.13.and the Heston and Safety
,MJQ.dc.saeaonus3a(a)± / All roofs shall be inspected prior to any roofing material being installed.
❑Ya 6eTo
Will the applicant or future building=upon(t r.equipment or&vices which If a roof is installed without first obtaining an inspection,I agree to remove
I,haardnns air conomitants as diluted by the Bay Am Air Quality Management all new materials for inspection.
Unroll
❑Ya �]Mr
I hate mad the haaNcus materials raquiumeu underChapter6.95 ofdu Califon
nia gralah h Safny Codc,Scetiau 25X15.25533 and 25534,1 undeuond thuifde Wilding
doe not c rely hew a L that it is my Iaportsibi ily to notify Ne occupant of Ibe
(.quire which and tpriormissumccon Oordficauof span Signature of Applicant Date
r7 v +
or madthamed.gaol Date All roof coverings to be Class"B"or better
CITY OF CUPERTINO ?
SEIM
TEMP POWERCM OF �
UPERTINO PERMIT APPLICATION FORM
APN # D p Dat ` I?^ 03
Building Address:
7 y3 cAt4VA4•,C
Owner's Name apA4 t-fF y 5 Phone_
Contractor: Phone:see' License#:
C��✓cZ ��,� . - �3-7b�j3 P,>>/oZ39G
Contact: Phone: Cupertino Business License#:
,u ut edwz �o y �y3-7653
Building Permit Info:
Elect (�
Job Description: �� n
f'0 �G
Residential EK Commercial ❑
Cost of Project: /
� O
•
Qty, if
Applic l Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
?7
f2 ,
S