04040163 (2) CI'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR°INFORMACION '
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Bun-DING ADDRESS: JAY SYLVESTER CONSTRUCTION PERMIT N`04040163
0645 CULBERTSON DR
OW DWI
NAME: PERMIT LSSUE DATE
TONY SANCHEZ 109 MICHAEL WAY Q4/26/2004
ONE SANITARY NO. CONTROL NO.
(408) 307-2770
ARCHME:CTICNGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
o
°00
LICENSEDCONTRd under
DECLARATION
e to I hereby affirm that 1 am limned under provisions of Chapter Y(commencing lob Description
ainr with Scaion7IXN17of Division3 of the Business and Pmfcuinm adq. dmyliccnu is '
'may mBrnrreandeBee 6�1 ( EMP POWER
2v�z Liccnn Cl s Lu^p
nFw Date C tactor
ARCIIIIIi CTS DECLA
w w< 1 understand my plans shall be unit as pu c m orris a
JyU
soH
Licensed Professional
in
S OW N[R-0UILDER DECLARATION F
y 1 hereby aff lire titre am esmnpt from the Contractor s License Law for the ✓\
p O following reason.(Section 7031.5.Business and Professions Code:Any city or county v
K m which requires a permit to construct,char,improve,demolish,or repair any structure $200
poor o its issuance,also requires the applicant forsuch Permit it)File asigned stalemem
£ya that he is licensed pursuant to pmvidoox ofthe Contractm'slicensn Law(Chapter 9 Sq. Ft. Floor Area Valuation
yF� (commencing with Section7000)(ilDiviMon3 ofthe Business and Professions Codc)it
i
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 731ft#a GrO 0 Occupancy Type
not mon than five hundred dollars(S500). Pane Y YP
❑L as owner of the prorterty,or my employees with wages u their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code The Contractor's License Law dors not apply to an owner of Required Inspections
property who builds or improves thereon,and who docs such work himself or through his
own employe t,provided that such improvements are not intended or offered for sale,if,
however,the building or improvement is sold within one year of eom plction,the owner"
builder will have the burden of proving that he did not Wild or improve for puTou of
sale.).
❑1.as owner of the property,am eulusivciy contracting with licensed contractors to
construct the proycci(Sec.7614.Business and Professions Code:)The Contractor's Li
rue law docs not apply to an owns,of property who Wilds or improves Merton,and.
who contracts for such projects with a cutnramnr(s)licensed pursuant to the Cort acsor's
License Law.
❑1 am exempt under Sec. .B&P C for this aeon .
Do no, Date
WORKER'S COMPENSATION DECLARATION
I hereby affsm under Penalty of perjury am of the following declarations:
I has and will maintain a Certificate of Consent to self-insum for Worker'sCompcn-
mtian,m provided for by Section 3700 of the Labor Code.for the perfarman¢of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Code.for lite performance or the work for which this Permit is issued
My Workers Compensation Insurance carrier and Policy number an:
J� Caress Policy No,
/// CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the Permit is for one hundred dollars($100)
ser Isis.)
1 certify that in the Performance of the work for which this Permit is issued,1 shall not
employ any Person in any manner an as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnilicam of Exemption,you should
become subject to the Worker's Compensation provisions of the Ichor Code,you most
.J O forthwith comply with such provisions or this Permit shall W deemed revoked.
'Z CON STRUCTI ON LENDING AGENCY
Ihereby affirm that the m is a consuoction lending agency lonhe Performance of
the work for which this Permit is issued(Sec.YN7,Civ,C.)
W Q Lender's Name
O. Lender's Add.,
7z
U O 1 certify that I have read this application and Sate Net the above information is -
ly correct.1 agree to comply with all city and county ordinances and sum laws slating m
C.) building construction.and hereby authorim representatives of this city to enter upon the
abovrmemimmed property for for,amoism purposes.
Fd (We)agree re save,indemnify and keep harmless the City of Cupertino against
vs liabilitics.judgmcnm.costo antic ma which may in any way seems against City
V z in Co.gim of tit arcing ,this
ICAhT UN RSTAN 5 A WI C PLY WITH ALL NON-POINT Issued by: Dale
.. OU CEREGU IONS.
rills26 te Re-roofs
S' name fApplicaor (Date
HAZARDOUS
��• _ � I
fIA]"ARDOUS MATERIALS DISCLOSURE Type of Roo( \LLL/ f[vJ Y C
Will Bic applicant Or future building Occupant store or handle hararduus m menal
as doffed by the Cupefinn Municipal Code.Chapter 9.12,and the Health and Safety
Cudc, a 25532(x)?
0Y C]No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
sit haeamnus air cnnmminams as ddincd by the Bay Arca Air Quality Management all new materials for inspection.
Jihfict?
QYcs LI No
I have read the ba,orchms materials requirements under Chapter 6.95 of the Cahfnr-
nixHcalth&SafctyCtslc,$cctluns 5(15,25573 anJ 255}4.1 understand dtaifthc building
or• t nnremly hu lenam, tit it i ay rex sibilky,,nobly me meuPant of the
to iren rets which stM me Finn aCcnifwm of ac pafcy.
Signature of Applicant Date
O sours thodaedvgem Date All roof coverings to be Class "B" or better
Community Development
Mi
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408) 777-3333
#UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: o,,vY PHONE # 73 7 2 (J
GENERAL CONTRACTOR: J I FAX #
I am not using any subcontractors: Z 6 D
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
e'
TEMPPOWERTy
(�3
UPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
O �/ e vXSo H/ Jv
Owner's Name: Phone #:
Cnn,�ctor: Phone: License#:
S AlnSZ,e-f o 3o-7 2770 S6 q 1
Conta t: Phone: Cupertino Business License#:
Building Permit Info:
Elect
Job Description: ` n
Residential ® l QM Commercial ❑
Cost of Pro'ect:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
/ EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING