03110083 (2) CITY OF CUPEWI'INO '� "`' '� ''+r ` ' .mss ``u4.•'
BUILDING DIVISION PERMIT ' C0NT1UCT01Z 1NTORMATION
7RELLFL
DDRESS: THOMAS MCNAIR PERMIT N003110083
2226 MC LAN RD
OWNER'S NAME: PERM"ISSUE DATE
` OMAS MCNAIR 11/17/2003
NE: SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER; - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 0 0
jou LICENSED CONTRACTOR'S DECLARATION
II hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Sermon 7=1)of Division 3 of the Business and Profeseiom Code.and my license is
mB
inf,rce end anneal TEMP POWER POLE
j�I Z License Class Lic.0
F Dow Contractor
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
a
sot, Liecnsed Professional
.1 OWNER-BUILDER DECLARATION
<2 1 hereby affirm that 1 am exempt from the Contractor's License Low for the
O o following notion.(Section 7031.5,Business and Professions Code:Any city or emmy
e 3� which requires a north to construct,site,improve,demolish,m repair any structure 31)0
u Z i- prior m its isuance.also re uirm the applicant for such perminu fife a signed statement
< that he is licensed pursuant nthe provisions ofthe Comment's LiwnseLaw(Chaptcr9 Sq. Ft. Floor Area Valuation
[€'o
(commencing with Section 7000)of Division 3 of the B usbacm and Professions Code)or
Q $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fon permit subjects the applicant to a civil penalty of Or 0 Occupancy Type
not mom Nan five hundred dollars(5500).
I,as owner of the pmpeny,or my employees with wages u their sole compcnmdon.
will do the work,and the cwcdm is not monocled or oaered(or sale(Sec.7044,Business
and Professions Code:The Contractor's License law does not apply to an owner of Required Inspections
popeny who build,or imposes demon,and who dnnauch work himself or through his
own employees,however.
thebuilding
provided that such impmwd wit are not intended m pleeud for be
r.
however.Ne buildingde improwmem is sold within one year d completion,de owncr-
builder will have the burden of proving that he did not build or Improve for purpose of
.1.J.
❑1,as owner of the pr.ptny,am exclusively contracting with licensed contractors to
Conswct the project(See.7044,Business and Professions CWc:)The Convutori Li-
Cense Law does not apply to an owner of poperty who builds or improves them..,and
who contracts for such projects with a contramm(s)licensed punuam to Ne Connacbm" V
License Law.
lixNm ne no under See. B&P�C�
ODa¢1'((h(CL_
WORKER'SCOMPENSATIONDE R ON
Ihereby atfrm under penalty of perjury can of owing dalaralmne:
1 have and will maintain a Cenifcahl of Conunuo ulGinsure for Worker's Compcn.
cation,u provided far by Section 3700 of the labor Code.for Ne performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Imuran,as required by Section
3700 of Ne labor Cale,for the performance of the work for which this permit is issued.
My Workers Compemmion Insurance carrier and Policy number am:
Cartier: Poli,No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nand not he completed if the Permit is furore hundred dollars($IN))
or less.)
I certify that in the performanre of the work for which this permit is ismod,1 shall not
I mploy any son in any manner in ayt9lCcogc my�unthc Workers'Compensation
Laws of m'.Dna I LCD
Ann
N PLICA .a tar making this Ccmfic a should
be object to the Worker's Compensation provisions of de r CnJe,you moa
.,,'� forthwith comply with such prnvisians or this Permit he deemed cmeedmcd revnkaJ.
Z O CONSTRUCTION LENDING AGENCY
I hmehy affirm that Vert is a conewcto m lending agency lot tM performance of
x me work fur which this permit is issued(Sec.3097,Civ.C.)
CQ Lender's Name
= z Lender's Address
L)0 1 cul that 1 have mad this application and cum that the above information is
u.0 cortccngagreemcomply with ycity and county ordinances burl cost laws relating to
V building construction, hercbyaohori purposes. of Nis city memer upon do
G shove-mcntiwcd an thin foimnify an keep ha.
(We)agreer to cost,indemnity and keep harmless the City a Cupertino,aims q
incoises.Judgments,cosuandofpenusmiich may in anyway acerve againstvoid Ciry
V~Fjr
APPLICANT
of the UNDERSTANDS
of thisPermit,WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH 5��
A N-POINT Issued by: Dale
SO EREGU /
Re-roofs
i sere of ApPlicanVConsran ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the epplicem urfuwm building occupant nom or handle hamdom moronism as defined by the Contains Municipal Cade.Charier 9.13,and the Health and Safety
oda,Section 35533(.)7 All roofs shall be inspected prior to any roofing material being installed,
❑Yn �pN
Will the applicant or start buildingtrpanl s equipment which If a roof is installed without first obtaining an inspection,I agree to remove
it hvardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
n mrict7
Dyes 01114.
1 have real be havaNnoma¢rialsmyuirtments under Chnp¢r 6.95of Ne Califor-
niaHealth&Safety Cale,See oro 355(15,35533 and 35534.1 unlerstsnd died ifthe Wilding
Jon not currently haw a mount,that it is my responsihility in notify tht occupant of the
swhichCenifale f uparey�5 Signature of Applicant Date
ter or auth.f.d.,not ` 'Dionv All roof coverings to be Class"B"or better
CITY OF CUPERTINO
6 TEMP POWER 0.3
UPEkTINO PERMIT APPLICATION FORM
APN# Date:
11 ZI-7 o
Building Address:
222 G LEt L4n1 h /]
Owner's Name: Phone#:
0^►R1 I 4a
Contractor: Phone: License#:
Ow
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description:
,w Si i ISS G�
Residential Commercial ❑
Cost of Project:
Qty. f
A ._ c b Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING