05050087 (2) ` CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT NO.
QSP CONSTRUCTION 05050087
OWNER'S NAME: PERMIT I.55UE DATE
+
ONE: S A N ITA 2 OL NO.
wRCHITEC(ENGINEER: BUILDING PERMIT INFO
nELECT PLUMB MECH
app LICENSED CONTRACTOR'S DECLARATION
ZC I Mmby affirm Nat 1 am littmed under pro'cions of Chapter 9(commencing lob Dyeg�Crp1 tion on 3 of the Bppp
t6■ie
;<w
with Scotian 1p111)Uf DivisusiMv and Pfyfresium Codc.andmylicenscis f�tl B
in full farce and off .1�D/ H®"'tltl
;'y_ L;eenxeass_ _Lk.w 7f �4' TEMPORARY 'POWER
t ❑ Dato 7vl/ .� 1 CUnlrmtor
W�££',f` �TARCHI'IECTSDECLARA lc
ye C I undersand my plans shall be used u public rttnrJs ._�/j.*j�
k 6 u 1-w 2005
;off UkmscdPnrfcssionsl
3 OWNER-BUILDERexemptDE 0.CimaION' ���
1 Wrtse .(Sem Nm 11. exempt from Ne Cantracmr's :Any c Lew for the
p o fallowing anion.(Section 1031.5,Business and PmRasio i Calc:Any tiny or county
I- which mquias a gamin m cnmuuct,alar,impmw,dcmnli h,ter repair any swnum
iy prior m its issuance.also requires the applicantfor such permit to file a signed statement
< that he is licensed pursuant o the pmvisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area VaIuat On
(commencing with Section 70X)of Division 3 of the Business and Profusions Code)or
_ that be is exempt nbemfmm and the basis for the alleged exemption.My violation of
Secant 7031.3 by arty spPhesnt for a permit svhicm the appgcml to a civil penalty of 3-A_FV$tJ3ter0 0 Occupancy Type
not mom Nan five hundred dollen($300).
I,as owner of the property,or my employers with wages w their sale compensation,
will do the work and the awctum is or intended or offered for sale(Sec.7W,Business
and PmfItat Carlo;The Comosctora License law it=not apply to an owner of Required Inspections
pmpcny who builds orimpmaes Wu n,md who doessuch work himself or through his
Own employers,provided that such impmwmcnu sonar intended muffered forsake.If.
however,Ne building or improvement is sold within one year of completion.Ne owner-
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sato).
O h as owner of the progeny.am exclusively conumting with licensed contractors to
consimet Ne pmjcct(Sec.7044.Business and Professions Cade:)The Consecmrs Lb
more Law dors not apply to an owner of progeny who builds or improves themon,and
who contracts for such projects with a contraeou(s)licensed pursuant to the Contractor's
Lim.law.
0 I am exempt under See .B&PC for this myon ..
owner I-Y-Af✓14 PH-(e Nly Dat (G o
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following deerlaradonae
I hsw and will maintain a Cenifinte of Consent no xl6im a for Worked ComLim
sation,as provided for by Section 37M of tW labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation boson..as matured by Section
37X of the labor Code,for the performance of Ne work for which this permit is issued.
My
Wnrkc les Compo/motion Insurance testier and Polity number am:
Cartier: 1tA Tt L.-.d Policy Na.:
CERTIFl TE OF E%EMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is Taste hundred dollars(SIX)
or fess.)
I mfufy Nat in the perfarmsom of the work for which this permit is issued.I shall nor
employ any Nixon inany maAer
Laws of aI /o e.—
ecl to thWorkers'Compensaon
Applicant
NOTICE TO APPLICANT.If.aPkr malfing this Ccnucate of Exemption,you should
become subject to the Worker's Compmtssuon pm iisions of tW Lather Code,you most '
.JO fmUvRh comply with such provisions or this pormit shall be rammed.,.ked.
Z to CONSTRUCTION LENDING AGENCY
[r I hereby arm that them is a construction lending agency fa the performance of
E
ate work for which this permit u issued(Scc.309'1,Civ.C.)
ty 0 lender's Namc
Lender's Address
D Z
U O 1 rer ify than 1 have mad this application and sato that the above information is
U. F-' carccL I agree b comply with all city and county oNlnances and state laws alining In
0 V Wilding coaswclion.and hereby mtionec spicsomanies of this city M enter Upon the
C ahovcmcokmndp.K,ty for impeNan purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
F" h habil)ties,judgments,costs and expenses which may in my way awme against mid City
U Z APPL CANTeUNDERSTANDSthis
AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S R REGULATIONS. _
Re-roofs
Signanumof ApplianVCa for .- Dill
"H US MATERIALS DISCLOSURE Type of Roof
WWII the
app rmt or furore building occupant ttoa or handle havudous material
as defied to the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
COJc,Sccuon23372(a)I All roofs shall be inspected prior to an roofing material being❑Yea P P Y g g installed.
Will the applicant or future building Occupant use equipment or Jev;ces which If a roof is installed without first obtaining an inspection,I agree to remove
it haeamaas air contaminants as Defined by the Bay Area Air Quality Management all new materials for inspection.
Dinrict?
❑Yes [7 No
1havemadthehuarctions terials5533 amcntsunder Chapatr6.93of Ne Califon
nix Healthtumotl haveaSMant,do it
m333mo25534.1 undersand thatifthe Willing
Jots not camently have a tenant NUI it is my responsibility in nnwy the Mcupent of Ne
requormems which must be men prior wissuance of a Certificate of Occupancy. Signature of Applicant Date
ownerarm rx ge Dae All roof coverings to be Class"B" or better
' Community Development
10300 Torre Avenue
l Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
11 Y 3 W-A� o
OWNER'S NAME: PHONE # ti o 2 i 7 U
GENERAL CONTRACTOR- arpC p NI,T t FAX # o
I am not using any subcontractors: fl( o
Giaor�tHF Date
Please check applicable subcontractors and complete following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
S 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
aEl-
CITY OF CUPERTINO
TTEMP POWER
SCUINPEkT
O PERMIT APPLICATION FORM
APN # v 1 ;U� Date:
Building Address: i/
19 8 �-,, 4 -
Owner's Name: Phone #:
Contractor: Phone: (y Tq License #:
Co ov) ,Y2— 6 I �
Contacts Phone: C pertino Business License #:
Building Permit Info:
Elect
Job Description:
Residential Ln Commercial ❑
Cost of Project:
v �
Qty. if
Applicable Fee ID / Fee Description Fee Group
/ BTEMP Tem orary Power ) ELECTRICAL
EPERMITFEE Elect. Permiflssuance ELECTRICAL
BUSLIC Business License BUILDING
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