04090245 (2) CITYOFCUPERTINO ` ''" �
BUILDING DIVISION PERMIT C.CONTRACTOR=INFORMATIONN y. - . . .
BUILDING ADDRESS: NATIONAL CONSTRUCTION RENT "gr"14090245
OWNER'S NAME: PERMITLSSUEDATE
ONE: SANITARY blCONTROL NO.
A0.CHf1ECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIPCT PLUMB MECH
+00 LICENS§D CONTRA 'S DECLARATION Job Description
C I kmby affirm NPt 1 am licensed u r pmviaioru of Chapmr 9(commencing
b wiNSxdontgp)of0iviv6.3 fart u' Pmfeuluv Codc.andmyliccnsc is
rt'�d loraum.eanaerfo . t d TEMP POWER POLE
jai Li..Class a C7/
Z;: Do Deta 4 on DEC \ \
�y'�' ARCH SDECLARATION
ey n-s l understand my plan hall k used s public neemda ��
DnU \
Gt; Licensed Pndessiond
OWNER-BUILDER DECLARATION
I hereby nRrm that I am exempt from Ne Contractor's Liecnse Law for M
G O following mason.(Section 7031.5,Businass and Pores ons Codi:Any city or county
which.yuirm a permit to construct.altar,improve,demolish,tar repair any structure
Fri prior to its issuam..iden requires the applicant forsuch Permit file a signed statement
< that he is licensed runabout In NC Provisions of the Contractor la
ctor'a License Law(chapter 9 Sq. FL Floor Area Valuation
are (commencing with Section 70t of Division 3ofde,Business and Pmfessiom CndO)or
"I he is evempt Ncrefmm and Ik basis for the alleged caempuon.Any violation of A-ow1�M�.,,�a,
Stolon 7031.5 by carry applicant for a permit subjects the applicant to a civil penalty or .3 7AP3`1)N%9);ID 0 Occupancy Type
not mom Nan fixe hundred dollar(55001.
0 I,u owner of dta property,m my employes with wages asChir sole compewdon,
w II&Oework.anditswnumnno1in¢tadedmo@.dtorsCe(Sec.70aa.Busiwa Required Inspections
and Profusions Code:The Conmcmr's License Law it.ret apply to an owner of q P
property who builds or impmw thereon,and who does such work himself or Nmugh his
own empluyces.Provided that such impmvemen s are not intended oro@red for sale.If.
however.thc building or improvement is sold within one year of cOmDlction.the comu-
builder will have Ne burden of proving that he did hot build or imp nvo for purpose of
skJ.
0 1.as owner of the property,am exclusively contracting with licensed cormantta to
construct Ne Pmjcn(Sec.7014.Business and Porecdom Code:)The Comtaclors V-
cane law docs not apply In an owner of DropOrty who build.or improves thereon.reit.
who convects for such projects wilt a conmcmr(s)licensed pursuant on die Convaetors
Liumc law.
I.exemp,. uSee. ,B&PCI IN
Owner Date 2
y ✓ RK COMPENSATION DECLARATION
1 hemby affirm unit r malty of ramjcU One of die following dec stations:
I have and will maintain a Ccrtifcmm of Consent to self-insure for Wohm's Cnmpcm
stion,as provided for by Section 37M of die labor Code,for Ne performance of Nc
work for which this permit is issued.
0 1 have and will maintain Workers Compensation ImWance,as required by Section
3700.f die Labor COM,for the performance of dta work forwhich this pemtf is issued.
My Workces Compemation hu owed Cartier and Policy number a.:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEI
CITU section=it not becompleted if the permil lsforone hundred dollars(SIM)
or less.)
1 unify that in Ne Norom.nce or the wart for which this Permit is issued.I shall not
employ any person in any manner sn as to become subject to the Worked Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,afar making this Certificate of Eaemption,you should
become¢object m Nc Worker's Compensation provisions of the tabor Coto,you most
.J O ronhwith comply with such proviso.or Nu permit shall be dumcd forked.
ZN CONSIRUMON LENDING AGENCY
Fa I hereby aRrm that them is a convection lending agency for Om Performance of
[(,> the work for which Nis Dermic is issued IS..NRI.Civ.C.)
II]A Lenders Name
D. Lenders Addrtss
U 0 1 eenify that 1 have mad Nis application and state that the above infomadmi is
U. F' torten.1 agree to comply with all city and county oNinanus and sok levo.]ming m
OU building construction,and hereby au,Odm.pre¢natives or this city in enter upon due
�� above-menvordul property for inspection pmpmea. 3
F, (We)agree to save,indemnity and kap ham les,Ne City of Cupertino against
gy
,) liabilidu,judgmcnta.eosuandcapcmeswhichmayinanywayaccmeagaimtsidCity
U z APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 7 Z Z L)
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicanaCommnm Da.
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicam or future building occupant eta.or handle barase o r;material
as;dcri cd by the Cupertino Municipal Code.Chapter 9.13,and the Heal%and Safety
11o,
odt.Section a5533(a)7 All roofs shall be inspected prior to any roofing material being installed.
0y.
Will Ne applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
il hamrdnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes N
I have.W the hvardnusma.rials mquimmcnu under Chapter 6.95of the Califor-
iaHealthhSgctyCOM.S.d.25305.25533aN 534.1u . dthmlfthc budding
us not canto y hove a tenant Nat it h my resp ounility m ntify the occupant of a.q mwithmtrrtkmt loivasneetncen;fcala Gtetrpaner. SignatureofApplicant Date
Y All roof coverings to be Class"B"or better
wner or Ailonized age te
Community Development
10300 Torre Avenue
r% Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: / O � O f ,(.� � PERMIT # 6
OWNER'S NAME(: h PHONE # �f-
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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/Co actor Signature Date
CITY OF CUPERTINO
Sits- TEMP POWER
$ Y OF
CUPERTINO PERMIT APPLICATION FORM
APN # 3 CJS— o 2 Date: q /0
Building Ad/dress: I D Qo � 0 �(
Owner's Name: b L'VOyI Phone #v�V� _3
Contractor: (V
p ���� / n Phone: License #:
Contact: j _ , lo(0 Phone: Cupertino Business License #:
Building Permit Info: L
Elect ❑ o ()
Job Description:
Residential ❑ Commercial ❑
Cost of Project:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
76
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