04050009 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORdINFORMATION
BUILDING ADDRESS: _ CHEROKEE CONTRACTING CO. PERMIT Ncb4-050009
MR
OWNER'S NAME: PERMIT L95UEDATE
V
I
SAND HYA
ONE: SANITARY NO. CONTROL NO.
(408) 727-9850
CHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONO 1 hereby affirm mat I em licensed under p isiuna of Chapter 9(commencing Job Description
re See ] )af Division 3oftM Busincssa9 :'Ziomcndc.and my license isn 'm,,o fo def&cL 33So INSTALL LATERAL C/O
j�= Lkcnx ass 6 Lic.N
_o Data Contrxmr
�'3a ARC ITELTS DECLARAT
'�� 1 undersand my plana Mall he used u public records
OyU
Zo Licensed /C
Professional ,
3 a Y OpER DECLARATION
1 hereby.(firm that I am exempt F/
from the Contractor's License Law for emstthe
K T-
a O following reason.(Section 5.Business and All vfcssioCode:Any city ar county my O m� which.,at.a remit m construct,elm(,impmvc.demolish,or repair any structure
m—'^
prior fit its issuance.also rrquims the applicant for such Permit o file a signed statement
mat he is licensed pursuanuo the provision of the Contractors Llan Law(Chapter 9 Sq.Ft. Floor Area Valuation
at (commencing with section 70001 of Division 3 of the Business and Professions Cade)in
y that he is exempt therefrom and use,Ensu(m the allagcA exemption.Any violation of
Section 7031.5 by any applicant for•pchmit subjects the applicant to a civil Penalty of 3 5U0aQ5r1ber0 0 Occupancy Type
not mon man five hundred dollar(55007.
I,az owner of the property,or my employee with wages as their sole compensation,
will do the work,and me structure is not inmnded or offend for sale(Sec.7044,Business
and Prafcssiom Code:The Connector's Licelue Law does not apply to an owner of Required Inspections
property who buildsorimproves thereon,andwho doessuchwork himself orthrough his
sun cmployem,provided but such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within ane year of completion,the owner.
builder will hast the burden a proring that be did not build Or improve for purposu of
sate.).
❑1,as owner aalse,prvpcny,am exclusively contracting with licensed contractors to
columnar the project(Sec.7014.Business and Professions Code:)The Contractor's Li-
cense Law dors not apply to an owner of propnny who Guilds or improvex mere9n,and
who comment for such projects with a contractor(s)licensed pursuant to the Contractors lJ
License Lw.
❑ I am exempt under Sea .B k P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury One of the foilewng declarations:
1 hoe and will maintain aCcnificne of Consent to self-insure for WorkersComyen-
saion,an provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Cock,for the Performance of the wort for which this permit is issued.
My Worker's CompC?..n Insurances c.or and Policy number are:
Cartier: n� �Policy�! .
Jy CERTIFICATE FEXFMPf ON FRj 1WORKERS'
COMPENSATION IN5 ANCE
(Thu suction need not heeomplemd if rhe Permit is for one hundred dollars($10))
or less.)
I ccnify Jot in the performance or the work for which this permit is issued.l Mall not
employ any person in any manner an az to become subject 0 the Workers'Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Cenifmate of Exemption,you mould
become subject on the Workeh Comperuation previsions of the Labor Code,you mus
.J O forthwith Comply with such pmvisimu Or this permit shall be deemed rawkod.
Z CONSTRUCTION LENDING AGENCY
'T+ I hereby alliin that there is a construction lending agency for the perfomance or
!Yi
the work fur which this Permit is issued(Sec.3097,Civ.C.)
WW A Landers Name
=z Lendcr's Address
U 0 1 certify that 1 have read this application and sum that the above information is
W (•-' comet.I agree to comply with all city and county Ordinances and sum laws relating 10
0U building constriction.and hereby aumerirz reprexnutiwIs of this city to enter upon the
above-memioned pmpcny for impaction purposes
Fa (we)agree to save,indemnify and keep harmless the City of Cupertino gains(
Ig liabilities,judgmcnu.cmts and carcinoma which may in any way accrue against slid City
U Z in consequence of the granting of his Permit. '1,
.^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU C EGULATION , n )
S��"Q !V+ /r— Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willtheapplies. or forme wilding occupant Gore er handlchvallous material
az deGncd by rte Cupertino Mun'real Cali.CTaPter 9.12,and me Health and Safety
WC.Scram zss3z(an All roofs shall be inspected prior to an roofing material beim
❑Yes No P P Y g g installed.
Will the ap,liC. I or rani building occupant tax cyuipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
coir harnrdnus air cmto it u in' de0ned say ma Oay Arca Air Quality Managcmcnt all new materials for inspection.
District? @JN
❑Yes
I here mad the bvardon s materials recommen s under Chapter 6,95 of the Califor.
nuHealth& ataxy Code.Scivnv 25X15,25533 and!25534.1 undammnd ma if the Nilding /� `T / / L
Jam eros cu Uy hoc a tenant than it is y rupossibiliry to notary the acO,.t of the u
nuimm h¢hmust anal uatecaf.ccrtifcamof ccuen Signature of Applicant —s Date
4 S '" Q� • � �? P cY
lA —If1„ kll L Q
Onr6craraemerivadagent ro All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
If
to Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
II -46UPE(�TINO
Building Department
I:
JOB ADDRESS' PERMIT #f
! o
OWNE 'S NAME PHONE _ 'J
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: _ 2a--Mc 1 —z T
Signature Date
Please check applicable subcontractors and complete the following information:
60 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
CNP/Contractor Sign Date
CITY OF CUPERTINO
ana REPIPE/SEWERS/MAIN SERVICE
CITY OF
CUPEkTINO PERMIT APPLICATION FORM
APN # D / o /�� Da
(� s � m
Building Address:
`7 7 fe / 2 u
Owner's ame: Phone#:
-/z7 -9 � c�
ractor: t one: 72 7— License#:
Con Phone: Cupertino Business License#:
�+ ,( I -0 v
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job�Description: ba L es 0
L
Residential C 7
ercial ❑
Cost of P oject:
•
Qty. i
Appli6W Fee ID Fee Description Fee Group
PPERMrFFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
i BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING