05090012 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMITQNTRACTORINFORMATION
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BUILDING ADDRESS: S .P. CASPARY CONSTRUCTION, PFf�"O05090012
104-40 MTT.T,F.R
OWNER'S NAME: PERMIT ISSUE DATE
CAROLYN BOWKER 1765 PARAD 5
ONE: SANITARY NO. CONTROL NO.
(408) 779-1389
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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coo LICENSED CONTRACTOR'S DECLARATION JobDescri tion
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with 1 hereby affirm IMn I 1 sm licensed under provisioof Chapter 9(commencing p
Section 7afgn of Division 3 of the Business and Professions Code,and my license is
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�= License Clue useN
Dam Contractor
ARCHITECTS DECLARATION
U 1 undoshell
rsenJ my plans bo used as public mmNs ,
3 p G Licensed Profcmin al
3 OWNER-BUILDER DECLARATION
.�<F I hereby affirm that 1 am exempt from the Contractors License Law for the
D O following mason.(Section 703 L5,Business and Prefeasiun Code:Any city or county
m which requires a permit m cnnanel.alter,improve,demolish.or repair any structure 2 Q Q
r z< prior us its issuance.also requires the applicant for such Permit o rile a signed statement
thatbo u licensed pursuant m the provision of the Contractors Icon Law(Chapter 9 Sq. Ft. Floor Area Valuation
as (commencing with Section 7")of Division 3 of the B usinss and Professions Code)or D
that he u exempt therefrom and IIIc basis for the alleged caemption.My violation of ZV
Section 7031.5 by Wry applicant for a permit subjects the applicant to a civil penalty ofQeQU
not more Nan five hundred d.ii.(SSW). r ParaC Y Type
Ej I,u mwncr of the pmpwy,m my employes with wags u their sole eompcnmtion,
will do the work,and Ne s remum is n tEbrunded oroRered forsale(Sec.71314,Business
and Profusions Code:The Contractor's License Law does trot apply to in owner of Required Inspections
property who builds w improve theoon,and who docvuch work himsel f or duough his
own employees,provided thm such improvements me not intended oroRered formle.IL
however,the building or improvement is sold within one your of completion.the owner.
builder will have 0te Wrden of proving NW W did not build m improv far purpose of
sale.)./
�(,u M.,of does p open,am exelmively contracting with licensed..new.to
construct the project(Sec.7014,Bell..and Poefumimns Code:)The Commuter's Li.
cense Law does not apply in an owner of Property who Wilds or improves dation,and
who contracts for such projects with o conmcor(s)licensed pursuant o to Cormieh
License Law.
❑Ism eae pt under
��sefaflI /A` ,s-,, B&PCforthistemon
Owner ��_AX91_ A W 4 Date 9 Z o
1[137WORK 'SCOMPENSATION DECLARATION
1 hereby affirm under penally of perjury,one of the fallowing declarations:
I ham and will maintain a Cerdfislo of Consent in self-intra for Wmrkefs Comycm
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ch.as provided for by Section 37M of da LOW,Code,for Or performance of the
rk for which this permit is issued.
1 have and will maintain Worker's Conformation Insurance,u required by Section
ofthe Labor Code,for the performance of da woh for which this Permit u issued.
Worker's Comensation Insurance carrier and Policy number artrier. Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed if ft Permit Is for ane hundred dolian(S 100)
or hem.)
I cenify our in to performance of IW work for which this permit is issued,I shall not
coployany person in any..no am fi(ome subject to IN Workers Comperemen
lawsmf Calif ia.Da¢ U
Applicant
NOTICE TO PLICAN If,after making Nu Certificate of Exemption,you should
become subject to the Workers Compenztion provisions of Ne UMr Code.you mus
.J Z foMwith comply with such provision of this permit shill cdeemed rooked.
zO CONSTRUCTION LENDING AGENCY
Ihereby affirm Nat term is a coommction trading agency for the performance of
a > the wash for which this permit is issued(See.3091,civ.C.)
lU0 Unders Name
a.z Lender's Address ,
U0 I certify that 1 hum road this application and sum Inas the above information is
D. F correct 1 agree to comply with all city and county until......sodium laws relating to
building construction.and hereby southern repmarmadms of this city o color upon de
O U W abovcme timed property,fm inspection pulfwses.
t„t 4 (We)agree to save,indemnify and keep humtrm dee City of Cupertino against
h IiebiliOs.jWgmcnu.esu and sperms which may in any way accrue against mid City
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in consequence of the granting of this permit.
^' APPLICANT UNDERSTAANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
3CDate
5 CE"RED
'1,t)k,P,k Re-roofs
HAZARDOUS
Srgnwrc of Ap lca ( Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building occupant sore or handle hanrdand
u armed by Cupertino Municipal Code,Chaplof 9.12,and da HcilN and Safety
CWc.Sc❑c Yo;25 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7d.,,
m haaodnus air conuminnts u dcrincd by de Bay Area Air Quality Management all new materials for inspection.
4
❑Yes Nu
1 have read the hvatdmrmamrials requitimcmu um k,CMplot6.95of the Calif.,.
Health&SafetyCodo,Senior 25505.25533 and 25531.1 understand lher ifthe Wilding
not curcntly have a tenant,thus it is my.,.I hility m adlyto up rt ofNe
atswhmhmmWW Iprkut, an coof.cmlicaloorlx p Signature of Applicant Date
Owner or euthonv agent z D to All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Oto _
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
ruffkjINO
Building De artment
JOB ADDRESS: PERMIT #
b4.3o KIIQ.rAvp,
OWNER'S NAME: 5340 6-71(j)
GENERAL CONTRACTOR S P (2&5 . or mSk. FAX #
I am not using any subcontractors: 8�
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
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Owner/Xntractor Signature Date
CITY OF CUPERTINO
Sa4l 'TEMP POWER pS-z� lZ
CITY 01
UPEkTINO PERMIT APPLICATION FORM
APN # t> Date:
L 37 So y =r ja o,�
Building Address:
j M ;
Owner's Name: hone#:
Ltz r-61 Pio wk� 40$ 40t -11 yr
Contractor: Phone: License #:
SIP. Cas aLr �&9 .
Contact: n II-- Phone: Cupertino Business License#:
C 0 I 611)
Building Permit Info: 1
Elect S r t I y dY c� r POS tlP.r 2 U1� Ql b
Job Description: nn -
Residential Commercial ❑
Cost of Project:
Qty. if
Ap2licable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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