06010136 (2) CITY OF CUPERTINO nA '" 'r�
BUILDING DIVISION PERMIT ;CC)NTRAC'f'URTN' UiMATION.
BUILDING ADDRESS: PERMIT NO.0 6 01013 6
10571 J OHNSON AVE
OWNER'S NAME: PERMIT L5UH DATE
f RICHARD HORTON 01/25/2006
NE: - SANITARY N0, CONTROL NO.
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG EO PLUMB ME�CH
pop LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby afOrm consop
Nal 1 am li
ed under provisions of Chapter 9(commencing
with Section 7")of Division 3 of the Business and Professions Coda,and my lismam is
in full force andeITCCL TEMP POWER POOL
e License Clue, Cm 101 CONTRACTOR: LUCKY PORTABLE SERVICES
g Date 7TSD ECL
3
Anasm]bnne DECLARATION
< 1 understand my pleonasm]bo cud a public remrdr
k c Ut, Licensed Professional
- OWNER-BUILDER DECLARATION
CantrON
COO hereby musen alRw onn 1 am"cmpt from W Cortins Co License Law for the
COO O following meson.(Section]1131.4 Business and Profusion Cade:Any city or county
3§r which requires a pewit re enuwct alar,improve,Frave;demolish.,li repair od ntemum
Z len prior u its Wnsed pursuant
requires the applicant Forsuch Cornu cutttsolim icco mLaw(Chapter
�< that mini gwit pursuant 10 the provisions of there Buinessand Pro loons Coiter9 Sq. F[. Floor Area Valuatio
$ (caths Is
(commencing with Section 71 andbssDivision 3of alleged
Business and Professions Cade)of
�.. Net he V exempt therefrom and the buss for the alleged Gumption.My violation of ppb N
Section 7031.5 by any applicant far a pewit subjects the applicant to a civil penalty of 3 7 5 2 7�� r 0 0 Occupancy Type
an It.not more them hundred dolun(5500).
❑1,as owner of the property,or my employe"with wages u their sole compensation,
will do the wart,and the structure is not intended or offered for age 70th.Business Required Inspections
"
and Footlessness wus
Code:The Coon m
Licee Law doe nsors not apply an an owner of q p
property who builds or improv"thereon.a nd who does a tach work himself or through his
own employees.provided thatueh improvements amort Imen sod moRered formals.if,
however,the Wilding or improvement is sold within one year of compkuon,On owner.
builder will have the Wrden of proving Net he did not Wild or improve for purpose of
sam).
I,u owner of the properly.am"elusively contracting with licensed conuacbn to
mtmct the project(Sec.7044,Business and Profession Code:)The Cuntracur's Li.
come law docs not apply u an owner of property who Wilds or improves thereon,and,
who contracts for such projects with a conuutor(&)ll"med punuam to IW Contractor's
License law.
❑lam sacro/Pty/Qde�r S{pc�-t .B&PCfmthearecon
I
Date
ORKER'S COMPENSATION DECLARATION
I hemby aOiw under penalty of perjury ane of the following d"lantiom:
I lore and will maintain acerincem ofconunt to snit-ineam for Warker'sCompcn-
on,u provided for by Section 3700 of the labor Cade,far the performance of the
rk far which this pewit is issued.I have and will maintain Worlsri Compensation Imurartco.u required by Section
0 of the Labor Code,for the performance,of the work for which thin pewit u Wised.
Worker's Compensation Insannce carrier and Policy number art:
Cartier. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu"cum reed not W emnpleted if the permit is fmarmhundred dollars($100)
mit.)
1 cenify that in the performance of the work for which this permit is issued,l shall not
employ any Person in mymanne"'Ieco tyt
l bj"tm de Wrke
on'Cmopen"O"
Laws of California.Date
Applicant Z-♦:
NOTICE TO APPLICANT:IL afar making N s Ceni0cale of Exemption,you should
became Subject he the Worker's Compensation provisimu of Ote labor Code.you most
.,0 forthwith comply with reach provisions m this permit shall be domed rewked.
Z "" CONSTRUCTION LENDING AGENCY
F+� I WrebyaRirm dor there uaconsvucum kendingageney forthererfmon.of
ce the work for which this permit u Wised(SOe.3097,Co.C.)
Idd Q finder's Name
z Lenders Address .
U p 1 certify Nat I have seed Ws application and sou that the above informaum is '
GL (r' coreca I agree m comply with all dry and county ordinances and sum laws relating on
OU building construction,and Wesly authorim repeamuiws of this city to enter upon lad
W above-mentioned propcny for IMPectian Purposes
, (We)agree to ave,indemnify and keep harmless the City of Cupertino agaiut
y liabilities,judgments,cuts ud expenses which may in any way aceruc against said City
U 2 in consequence of Or gMOng Of this permit y I L U
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b Date
SOURCELATWNS.
m �i l- Z5=C� Re-roofs
Signarure of AppliaHAZAmRDOetor Dau
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF 1.
Will 1hcapplicant or house building occupant soortnehandle incautious material
'az defined by the Cupertino Municipal Cade.Chapter 9.11.and the H"Ith and Safety
oW, Ovan15531(a)? l� All roofs shall be inspected prior to any roofing material being installed.
❑Y" .tl�Ne
Will the applicant or future Wilding Occupant rex equipment or,dcvias which If a roof is installed without first obtaining an inspection,I agree to remove
It huardom air canmearinuts as de0ned by the Bay Arta Air Quality Management all new materials for Inspection.
❑Y" (xp�Nu '
I have read the hasaNmts materials rcqu iremcw under CMpur 6.95 of du Cal irm.
me Health&SafetyCode,Savlxs 25505,25533 road 25534.I understand than if the Wilding
does not currently now a tenant Wt it u my mapomibility,to notify the oaupam of the
rtqui Once wuhmost be met Pon rmWuanccofaCesuO"teafOttupu Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent Dau
Z� -7 Community Development
10300 Torre Avenue
It Cupertino CA 95014
Telephone(408) 777-3228
CITY 0, Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT# /
`b .r 7 / j-o 4 rt rev, �� nO /c"/
OWNER'S NAME: PHONE #
GENERAL CONTVXCrOR. FAX #
I am not using any subcontractors: P,, / -2S
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
OO TEMP POWER,
ICUPEkTINO PERMIT APPLICATION FORM
APN# Date:
3 z / - z s--
Building Address: 11
0.s7Sohr7
Owns Name: Phone
o :
� p3, ti 13z-
Contractor: Phone: License #:
v �n('�b S P�'✓�
Cc act* Phone: Cupertino Business License#:
lltr.'�rvt-k 40rron 2, 1656
Building Permit Info:
Elect
Job Description:
�c'm / owe' `I,-O( ( t r'0r Tol2e�r,
Residential Commercial ❑
Cost of Project: 13 po
Qty. if
ApplicablFee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING