04090261 (2) 72�
CITY OF CUPERTINO - ^'-
BUILDING DIVISION PERMIT „A.CONTRX1 TT R,�IANF0RMATI0N `x
BUILDING ADDRESS: LARRY FU PERMITNO04090261
OWNER'S NAME: PERMIT ISSUE DATE
Alk LARRY FU
11 JNE: SANITARY 0. CONTROLNO.
BUILDING PERMIT INFO
ARCHITECT7ENGINEER: BLDG EIEC( PLUMB MECH
0 0 0 0
LOp LICENSED CONTRACTOR'S DECLARATION Job Description
Ou I hereby alftrm mat I an licensed under provisiotu o
of Chapter 9(commencing P
with Section 7")of Division 3 of the Business arta prolessimta Cade.and my Boons is
jqOr in full f.ni effect. TEMP POWER POLE
= Licenseclasslie.a
�— d Dau it as p r
qFq� ARCHITECT'S DECLARATION
understand
2� I undernd my plans all W=usev public mcnrds
JyU
Licensed Pnsfcssional
OWNER-BUILDER DECLARATION \
yt 1 knottyromm a?on Nat 11. exempt from tpr G..Bamao :Any ccnae Law far rho
i o O following moon. Peron n IID 1.5,Busher.and sae.de io demolish.
Code:Any city m eaumy
which rots jims a permit re corsuwm,alter,improv,de ermit t,m repair any awmure - -
prior Wire isswOcO.also requires Use applicant for Such Permit frees signed statement
rz< that ponvismses of Sq. Ft. Floor Area Valuation
¢F$ (commencingNumin Sectacrefroon and of Division 3 the
the Business and Proon.Any
Cade)im.of
— dot he k exempt Btertfrom and the Erik for the Nlcgcd exemption.Any violation of
SeNon 7031.5 by any applicant for•permit subjects the applicant to a civil penalty of 3 74PMM t (;r0 0 Occupancy Type
not mom than fin hundred dollars(5300).
I.ma nvofthepmpeny,Ormyemplo withwageev Neirmleeamp nutlon,
will do the vola and theawnurt is nasintetWedmoRemd fonds(Sec.)OU,Bum— Required Inspections
and Prefessimu Code:The ConuacmYs License Law does not apply W a.owner.f q P
property who builds&improves Hereon,and who does ouch work himaclf or through his
ownempkines.Provided that such improvcmcnu art notinunded aroRertd for vee If.
however.the building or improvement is sold within one)ear olcompieion.the owncs-
builder will have the burden of proving that he did nos build or improve for Purpose of
vee.).
v
co I,as owner of ct Seenproperty.em c mess nd contracting with:)The
contractors m
come La the Project(Sec.)OLL weer of and Professions Code:)The Conhemon. nd
ceone law dors nos apply c m owner of progeny who Wilds or improves Noma and
whonse Lacs for such projects with a conuusm(s)licenud pursuant m tK Conuutoh
License law. -
❑Iamexempt under 5eu .B&P C for His
o*9,i, Li ,-wDate
W KER COMPENSATION DECLAK
I hereby affirm under penalty of perjury oneafthe following lamtiaro:
1 haw and will maintain a Cmtificate of Conant a see0inaum for WofkcrsCompcn-
.,I..u provided for by Sec ..3700 of the Labor Code,for the pert...of the
work for which His permit is issued.
❑1 ban and will maintain Worker's Compereation Insurance.v mquimd by Section
370(1.(the Labor Cade.for the Performance of the work:for which this Permit is issued.
My Workees Commmadon Inwnnm carrier and Policy number ate:
curio. Policy NO:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu aectiun recd not becompleted if the permit Is formulsundred dollars(SIM)
or less)
1 sonify that in the performance of the work for which this Permit Is issued,l shall not
employ any Nixon in any manner an ss W become subject W the Workers'Compensation
Laws of Califomia.Dau
Applicant
NOTICE TO APPLICANT:If,a0er making this Cenifiote of Exemption,you should
bceome subject to the Worker's Compensation pmviaiom Of the Labor Cods,you mom
.0 z fordtwith comply with such provisions or this .,r iLshall W deemed revoked.
z CONSfRUCfIONIENDINGAGENCY
(..tom. Ibeuhy oMrm Net there iso emuuvainn lending agency for the perfurmmce of
�i t7 He work fur which this Permit is Wood(See.3097.Civ.C.)
D]A Lenders Name
D. lenders Addmss
U O 1 certify that I haw mad Nis application and sou that He above infotmniun is
F correct.1 ages in comply with all city and county aNinanas and stain laws relating W
�U Wilding construction,and hereby authorim tepreuntuiws of His city to enter upon the
r W above-mmu.ned property for inspection purposes
6 (We)agree to cave,indemnify and keep hummicas the City of Cuponirto against
wFa rat liabilities,judgments.costs and expenses which may in any way secure agaiMt said City L
U in consequence of the granting of this Permit. Date O
APPLI NT.UN RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOU RE L NS, I
� -4 T-it �1/° Re-roofs
Signwumof Appli.VCon ter Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar forum building uecupent stem m handle haOOdous maurial
as defired by Be Cupertino Municipal Code.Chapter 9.12.and He Health and Safety
Code.Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future Wilding Occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haraN.us air contaminams as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
p Yes Nu
I have reel He havardnus maurials reyuircmcn¢undery�lh�mur 6.95 of the C.Idm,
nia Health&Sefcty Coda Sceuoro 25505.25533 and2S536:ga/dcom nd Hu if thc Wilding
dura note tIY haw a isro nl Hat it s my responsibility W noufy the oceupens of the
m 'm n phichmustbemetPdoruissuanecof.CcrufsalcofOccupanry. / Signature of Applicant Date
�- is /o/ All roof coverings to be Class"B"or better
Ow urauthoriacdagen Dam'
Community Development
f` 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY 0, Fax(408) 777-3333
�UPEkTINO
Building Department
JOB ADDRESS: / p 73 a— J n h 5 v,, -lf o e PERMIT# OgF?jl
QL6
OWNER'S NAME: l — r — PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 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
OwnerJtontractor Signature �,J Date
'
S(FRItm
CITY OF CUPERTINO
apt z:) 2
TEMP POWER Y
SCUPTEk
INO PERMIT APPLICATION FORM
APN # 37-5- 9 0S-5, Date:
Building Address: I v 73 ( f o n 5 o h �c� _ / ,,F ,e— ;e--rL P
LI
Owner's Name: 1 � r F j i!, V Phone #:
Contractor: /am--rr ( Phones 5 —67-2-) License#:
l
Contact: bzTr Phone: >-.I;-5- — Cupertino Business License#:
Building Permit Info: Q !�D 6,o b
Elect ❑
Job Description: py`.7 ( a a—✓
Residential Commercial ❑
Cost of Project: 3oo_a�
•
i
Qty.. f
A 1f Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE 'Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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