05080271 (2) CITY OF CUPERTINO "
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION,
BUILDING ADDRESS: COLOA CONSTRUCTION, INC PERMIT NO.05080271
22291 CUPERTINO RD
OWNER'S NAME: PERMIT ISSUE DATE
CUPERTINO ESTATES, LLC 1671 CANYON VIE 08/31/2005
ONE: SANITARY NO. CONTROL NO.
(408) 891-2449
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
_oo LICENSED CONTRACT'OR'S DECLARATION O O O O
z ce P I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
�Zw with Section 7000)ufDivision 3 of the Business and Professions Code,and my license is
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p��
License
s Lie.
o Dam % Contractor G
CHITECTS DELLA r or FIA ,�,raJ.,r,P;',It, fypp
tey a a I understand my plans shall he used as public records p �d
D i D
C y
Licensed Professional / /
g Oat I am exempt
from
DECLARATION O
<y I hcrohy affirm mm I am exempt from the Contractor's License Law for the g p 01i.0p 70 [
O O following reason.(Section 7031.5.Business and Profesxiam Code:Any city or county N �p IP@b d 4,/ $150
X
m which requires a permit m construct.tiller,improve,demolish,Or repair Soy stmcwm
prior to its issuance,also requires the applicant for such permit to file a signed statement
�2a that he is licensed Pursonntto the provisions of the Contractor's Lignac Law(Chapter 9 Sq.Ft. Floor Area '�' `�[J&UVpalbation�
w~n (commencing with Section 70M)of Division 3 o(the Business and Professions Code)or
that he u exempt therefrom and the basis for the alleged exemption.Any violation of U 'I
Section 7031.5 by any applicant for a permit subjects me applicant o a civil penalty of er Occupancy T e
nm mom than rive hundred dollars(a5U0). P Y YP
L as owner ofthe property,or my employees with wages as their sole compensation,
will do the work,and themodelum is not intended or offered formic(See.7W.Business
and Professions Code:The Contractor's License Law docs not apply In an owner of Required Inspections
property who builds m improves thereon.and who does such work himself or through his
own employees,provided mat such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,me owner-
builder will have the burden of proving that he did not build or improve for purpose of
cath.).
❑1,as owner of the property.am exclusively contracting with licensed contractors in
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's Li-
ceae law does not apply to an owner of property who builds or improves memon,and.
who contracts for such projects with a contractor(s)licensed pursuant to dm Comi actors
License Law.
❑1 am exempt under Be. .B&P C for Nis..an
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations:
1 have and will mainuin a Cerdfieam of Consent to self-insum for Worker's Compete
7C31].M
ion,as provided for by Section 3]00 of the labor Code.for the Performance of the
rk for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as teyuited by Section
of the Labor Code,for the performance of the work for which this permit is issued.
Worker's CompensatiionInsurance carrier and Policy number am:
ncer: /aMA-aM A Policy No.:
CERTIEIC'ATE OE LITION FRO RCS'
COMPENSATION INSURANCE
Cres section need not ho complewd if the Poirot is formic hundred dollars(SIM)
or less.
1 ccrofv that in me performance of the work for which this permit is Issued.I shall nut
employ any person in any manner so as m become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcase of Exemption,you should
become subject m the Workers Compensation provisions of me Iahm Code.you muse
.J 2 forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
`r. I hereby affirm that there is a cunsuuction lending agency for the performance of
W ,7 the work for which this permit is issued(Sec.3097.Civ.C.)
UJ Qlenders Name
IL z Landers Address
U Q 1 minify that I have read this application and suss that me above infomimion is
E' correct.1 agree to comply with all city and county ordinances and sue laws relming to
0U building construction.and hereby authoris representatives of this city to enter upon the
stove mentioned property for inspection purposes.
(~ 6, (We)agree to save,indemnify and keep harmless the City of Cupertino against
y liabilities,judgments.costs and expenses which may in any way accrue against mid City
A APPLICANT
ofinegranting Ofthispermit.
U z APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCFr REGULATIONS.
--rn� Cn^It�) at Re-roofs
Signamrc APPlican Can tovaG r � Dele
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will be applicant or future building occupant same or handle harudous material
as dofncd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
mae.sOwnss532(a>?, All roofs shall be inspected prior to any roofing material being installed.
Yes
No
Will the applicansor future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardnus air conuminants as defined by me Bay Arca Air Quality Management all new materials for inspection.
mrict?
❑yes �No*
I have read the luvardcus materials requirements under Chamerb.95 of the Califor-
nia Hcalth&Safcty Code,Sections 255(15,25533 and M534.1 and re=d thmifthe building
dors not currently have a mnant that it is my responsibility l0 notify the ocraeunt of the
nXecorents which moat be met poor hi issuance of a Certificate of Occupancy. Signature Of Applicant Date
�ne 1 amt o•a n�t'�=' !k �I ?a�'I All roof coverings to be Class "B" or better
. Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
2-ZZC) I C f(,, o Ki? .
OWNER'SNAME: C69nt-ftr4o Cs PHONE # 44�0$ –a 6)
GENERAL CONTRACTOR. C,L,64 Ce,r .1 FAX # C J 8 a �s-_ 0 3 ,fy
I am not using any subcontractors: / ' I0S—
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 6ate
CITY OF CUPERTINO
TEMP POWER os' P 17
5--
CITY 01
UPEkTINO PERMIT APPLICATION FORM
APN # `2 * 2/ — l — 17 Date:
Building Address:
2z-zq (
Owner's Name: Phone #:
CO )Z A O O
Contra tor: _ Phone: License #:
C 0 Go Ccrnls 406 YDS=e`I°7 I 72
Contact: Phone: Cupertino Business License #:
aUfl Cif e$ s=b90 )
Building Permit Info:
Elect ®. I NS�A�I b Testi ro vi c-'r I o C
Job Description: 1
Residential ea Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
l EPERMITFEE Elect. Pen-nit Issuance ELECTRICAL
BUSLIC Business License BUILDING
Z Z
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