04100195 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT cONTRACTOR,IN '012MATIQN x*:
6UILDING ADDRESS: - PERMIT NO.
04100195
OW NER'S NAME: PERMIT k4UE DATE
ONE: - - SANITARY -. OL NO.
ARCHITECTB3NGINEER: 77
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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u00 LICENSED CONTRACTOR'S DECLARATION -- JOb DOSCTI hOn -
�i F I MrcbY affirm Nar 1 em limnacd under provision of Chapter 9(commencing -. p.. -, -. -
`�' Orion 'on7aln df0ividon3oflMBuurcsiauI oat Code,and my lie..is
TEMP POWER POLE C
Lhool oGas( f a' Lic.N
Ii^i� Da¢ ARCHITECTS DECLARATION _hit '�/�/�t�
I Ktundcrsund my plans s all h used arm M crtcnNa ---'—
7yU V l7
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3 OeYN am BUILDER DECLARATION
I hrchy alarm that I am exempt from Ilo Contractors Cu License Law for the
Z O O following reason.(Section](171.5.Business and Nofusity CoUe:Any city or coumy -
9 which requires a perms m construct.come Impross,d,nlfksh.In mPair any alauemre
He,Or its issuance,alsu mquims Ne applicant fors hath p,rmiuo Elea signed sidemen!
�z< that M is licensed pursuant to Centimeter.e prownimisof theCentimeter.Licenw law(Chapbr 9 Sq.Ft..Floor Area Valuatio
¢t-$ (commencing with Section 7000)of Division 3 of Use Business and Profession&Code)or - -
_ Net he u exempt drer,from and the basis for the alleged et. ptiom Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicanuo a civil Pcvlty of 3-AFV7 }pter00 Occupancy Type
not more Nan I.hundred della.($M
will❑La sow nu of lh PropenY, re isnot moyw sale(Sm.
comp,nation.
and do Newark.endo: he Contractors
pots Liceeat La e d forma1 apply 70 a,Busivsa - Required Inspections
end nywitabu Cod,:The Co,there
.Ldwho Law tan rot apply b en owner Of
- q p -
owncam wM WilNmimp at suchimpromdwho doessucnworkhir ofeortMugh hishowever.
the building
or I Nal suchent Is sold
wit art not our Ofc or offered foresee.If.
morm-
Wilderr.Nebuilding or Improvement Is Oat did one year of eompletifrNe owe of
builder well have Ne burden of proving Nal h did nm Wild or improve for purpose of
alcJ.
I,as owner of the pmpcny,am aselusinly contracting with licensed emorecions m
cosmuuct the project(Sec.7044,Business and Profusdov CWE:)The Cunmebr's Li'
cave law don not apply in an owner of property who builds or improves memo i.and -- - ------ --- - --- -
whocontractsforsuchprejectswidhacommetor(s)Iicensadpumuanl mNe Comeacto/s
License Lew.
❑1 am exempt undo Sec. .B&P C for Nis reason
Owner Dai
WORKER'S COMPENSATION DECLARATION
I hrcby n1he under penalty of petjury one of Use following deactivation:
1 hart and will orhoW n a C,ntfsnb Of Covent to self hours for Worker'sCempen-
ation,as provided for by Section 3700 of the Labor Code.for the perfmmmlce of Um
work for which this Permit is iau,d.
❑1 bass and will maintain Workees Compensation Insurance.as required by Section
3700 of On,Labor Code.for Ne pmformacc or One ooh forwhich this permit is issued.
My Workefs Compensation Insurance carrier and Policy numbers.:
Cann "'fa .Oi Policy No.: - O C)
CERTIFICATE OF EKEMMON FROM
COMPENSATION INSURANCE
(Thea oLme need not be completed Rohe permit isforone hundred dirda.(SIM)
Mss.)
I eenify Nat in thea Performance of the work for which this permit is issued,1 shall not
employ anyperson in any amoncr an as b become subject to the Workers''Compinsec n
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject In the Worker's Compensation provisions of Ih Labour CMc,you muse
roMwith comply with such provisions or this permit shall W deemed ratted.
Z" CONSTRUCTION LENDING AGENCY
'pw4 Ihertby affirm NettMrtiu conatnmtinn lendin&apenryfotbeperfuvnanecOf
p:7 me work for which Nis permit is issued(Sec.3097,Civ.C.)
QLciah'!NMe
a Leadmes Address
V Q I certify that I have read this application and sub Nat the above information is
U. (-' concoct.1 agree to comply with all city and county ordinances and site taws relating b - --
0 V building covwcinn.and herebyeuthodm op.mutime of this city In emel upon the
abovomcnuwN property for inspection purposes.
6. (We)agree to save,indemnify and keep harmless Nc City of Cup,nino against
In liabilities,judgments.cosi and a.,.which ma,in sm,way aecrue against said City
U z in consequence of the grafin&of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG ATIONS. � /�l ,
/i/ ^ l-f Re-roofs
Signe re V o cI O b
H ARDOUS MATERIALS DISCLOSURE Type of Roof
11 pl nd Or future building Occupant nom or handle hvallous material
az dc'nc0 by Cupcnino Mon icipel Code,Chap.,9.I2,and the Health and Safety
Co de,,seedon35532(a)l All roofs shall be inspected prior to any roofing material being installed.
Yu -ANO
Will the applicant or furore building occupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaN"us air commitments as defined by Ulm Bay Arca Air Quality Management all new materials for inspection.
DISVI[17a
o YC!
1 have read Ute huarfloo mamrials eximmmcnm rrecrChpmrik95of U¢Caliror,
ma Heald,&Safety Com,Sections 255(15.25533 and25534.I undcrsund One fide,building
Utes not curt, ly have a I, or Nat it u my respovihitity b m5ufy the occupons or One
re,dou, ra Ibe eap"armiasuaectfac,nianmara,ap,cy. Signature ofApplicant Date
D, All roof coverings to be Class"B" or better
owateRun agent
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
�UPERTINO
Bu// ildinDe C/aJ�rtm
ent
M
JOB ADDRESS: PE
,P GD
�yS
OWNER'S NAME: G ✓G_n PHONE # eel G7S
GENERAL CONTRACTOR: FAX # Ssc�
I am not using any subcontractors: ! t
Signal — Date
Please check applicable subcontractors and complete the followin information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping t=
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
a-M TEMP POWER
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 .75 6 Date: /O G 9
Building Address-.
1695f-6;
Owner's Name: Phone #:
Contractor: Phone: License
Contact:. �/J - / Phone: / Cupertino Business Licehse #:
Building Permit Info:
Elect
Job Description:
Residential Commercial ❑
Cost of Project:
Q . if
A li b Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE 'Elect. Permit Issuance - - ELECTRICAL
BUSLIC Business License BUILDING
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