03110031 (4) CITY OF CUPERTINO
IO REPIPE/SEWERS/MAIN SERVICE
CUPEII;TINO PERMIT APPLICATION FORM
APN# f I C) Date_ 0-3
Building Address:
Owner's Name: r Phone#:
Contractor: P one: License#:
ttiwt S-O 5S24o
ont ct: Phone: Cupertino Business License#:
rB ' ding Permit Info:
Bld /C7 Elect ❑ r1umb
ob cription:
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Residential Commercial ❑
Cost of Project: A
Qty. if,
Applies Fee ID Fee Description Fee Group
PPERMITFEE Plumbin.g Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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CITY OF CUPF.RTINO —N '
BUILDING DIVISION PERMIT CONTRACTOR INNORMATION
BUILDING ADDRESS: AAA ELECTRIC INC PERMITNO.
10643 LARRY WY 03010031
OWNER'S NAME: 3245 STEVENS CREEK BLV APPLICATION SUB DATE
usKINE OSAMU AND MISAO 01/07/2003
(408) 557-8899 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� 0
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
e4 U 1 herMy off roe that I mr licensed under provisions of Chapter Y immencing p
with Scctinn 71XX1)n Uivixinn 3nf NC Buvinus s mylianso is
mod
oma
an rn�(V/ /° �e�'S m( n UNGRADE ELECT SER TO 200AMP
�y'aZ License CP . Lic.M
FN_ Dam C,intmct
ARCHITECPS D 'A ATION
FO
Admypl�nsshall uJaspublicreenrx �AN08 �®
KOyU
wig U. Licensed Pnilessional
OWNER-BUILDER DECLARATION
as P 1 Acrchy affirm Contractor's I am exempt from the
r's License Law for the a� U
600 following mason.(Section 703 1.5,Business and Prnfessinns Code:Any city or county
X<$ which"rims a permit to construct,alter,improve,demolish,or repair any structure
w pnonn iLvissuance,aLoro,mocs lhuapplicant forsuch pefmil to file asigno statementn
that he is licensed pursuant the provisions of Ne Commetnr's License Low chapter 9 Sq. Ft. Floor Area $27Cdltlon
itk (commencing with Section 7s(Xq of Division]of the Business and Professions Chile)or
wy 3— Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pesmil subjects the applicant to a civil Penally of
not more than five hundred dollars(5500). -3 iAPN be Occupancy Type
1,u owner of the property,or my employees with wages as their side compensation,
will do the work,and Ne structure is not intended or offered for sale(Sec.7044,Businw 183 — UFER
and Professions Code:The Communes License Law does not apply to an owner of 304 - ROUGH L l,'IK'l LIOnS
pmpeny who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not Intended oroffewd for side.If, 505 — FINAL ELECTRICAL
however,tie building or improvement is sold within one year of completion,Lou owner-
builder will have the burden of proving but he did not build or improve for puryox of
sale.).
❑ h as owner of Ne property,am exclusively contracting with licensed convectors l9
consmuct the project(See.7614,Business and Professions Code:)no Contractors Li-
cense Law does not apply m an owner of propeny who builds or improves Thereon,and
who conbucm for such projects with a contractors)licensed pursuant to the Conuacmr's
License Luw.
❑I am exempt under See. ,B&P C for this reason
Owner Data
WORKER'S COMPFNSAT10N DECLARATION
I hereby zRfm under penalty of perjury one of the following declarations:
I have and will maintain a Cenifcate of Consent to self inion,for Worker's Compeer
ration,es provided for by Section 37W of the labor Coda,for Ne performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,u required by Section
37tH)of the labor Code,for the performance of the work for which this permit is issued.
My Wur ompenmlinn Latium.
CrOrmi and Policy nu he
rticr. ~'/ Policy Na: ��
CERTIPICA'TE OF EXEMITION FROM RKERS'
COMPENSATION INSURANCE. .
This section need not he completed if tk permit is for one hundred dollars IS 100)
or let..)
I cenify that in the pcfforrou ce of the work lot which this Permit is isoned.I shall not
employ any person in any manner ao as to hccomc mbjecuo the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of EAem pfion,you should
become subject to the Worker's Compensation provisions nl'the Labor Code,you must
Q z forthwith comply with such pnwixions or this Permit shall he deemed revoked.
'Z O CONSTRUCTION LENDING AGENCY
I--i I hereby affirm Nm Nee is a construction lending agency for the pariontroce of
ai 7 Ne work for which this permit is issued(Sec 3897,Co.CJ
(3t Q Lender's Name
a Lender's Address
� z
U O 1 cenify that 1 have read this application and slam that be above information is
^^F correct I agree to comply with all city and county containers and some laws helping to
DU building construction,and hereby authorim reprasenmlives of this city tocnmr Open the
above mentioned property for inspection purposes.
We agree m save,i dcmonly and keep harmless the City of Cupertino against % t
V) liabilities.judgments,cos d expenses which may in anyway samstsaid City
n consequence of the or gof this permit.
U z in
ER NDS AND WILL COMPL511;L17
N-POINT Issued by: Date
SOURCE RP I
Sig of Indi onoach Dam Re-roofs ,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Lie applicant or future building occupem store or handle haaoous material
as defined by the Cupertino Municip iter,Chapter 9.12.and the Health and Safely
Code,sereno z5s]z(arr All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applinm or future Wilding oceupatn sex equipment or devises which If a roof is installed without first obtaining an inspection,I agree to remove
not hvartho s air contaminants as depno by the Bay Area Air Quality Management all new materials for inspection.
District?
0Yes 11
1 have real the haamtoms materials requiremenu under Chapter 6.95 of the Califor
ma Hcalrb&Safety Code, ons 25515,25533 said 35534.I unJesecand Na if the building
does not cmmm ve that it is n respnns,b jity a nndf the o><nupam of the
req m ors nmprioumsuananraceina 2r,. Signature of Applicant Date
Owncror thori¢dagcnl SDmc All roof coverings to be Class "B"or better