06020095 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC-TOR�INFORMATION
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BUILDING ADDRESS: PERMIT NO.0 6 0 2 0 0 9 5
18_615 RALYA CT.
OWNER'S NAME: PERMIT ISSUE DATE
QI LIN 02Z15/2006
NE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
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u00 LICENSED CONTRACTOR'S DECLARATION
u❑ I hemby affirm that I am Ilcensed under provisions of Chapter 9(commencing Job Description
�W with Section 7")af Division Sof NC Business and Professions Codc.and my lim.is �'
in full TEMP POWER POLE
j y�? Lfullf chis Lie•
�F, Date Contractor
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ARCHITECTS DECLARATION
WU I undersund my plans shall M used as public meords
o Lic,nud Pmfcssional FEB al- 1006
g OWNER-BUILDER DECLARATION
<P I hereby affirm Nat I em exempt from the Contncmr's Limn.Law for the
00 following mason.(Schon 7031.5.Business and Pmlesdom COM:Any city or county
2
20! which requires a permit to consumer,alter.improve.demolish,or repair any structure 0
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prior m its issuance.also requires the applicant for such permit to file a signal statement
E O that he is licensed purwant to the provisions ofthe Cantsactur's Licevc law(Chapar 9 Sq. Ft. Floor Area U 1
yh (commencing with section 7")of Division 3 ofthe Business and Pmressions Cudc)ur
y that he is exempt therefrom and the bass for the Alleged exemption.Any violation of
Section 7031.5 by any,applicant for a permit subjects the applicant m a civil penalty of
not mom than five hundred dollars(s500). r Occupancy Type
❑1,as owner of the property,m my employees with wages As their sole compensation,
will do the work,and theswctum is rut intended or offered for sale(Sec.7044,Romans
And Professions Code:The Conumuses Limme Law does not apply to an owner of Required Inspections
progeny who builds or improve hemon,and who does such work himself or through his
own employers,provided that such improvements am not intended tampered for sale.If.
however,the building or improvement is sold within one year of complNon,the owner.
builder will have the burden of proving that he did not build or improv,for purpose of
rale.).
1,as owner of the pmpeny.am exclusively contracting with licensed convectors to
c wet the pmjcct(Sec.7W .Business and I'milusions Code:)The Contractors Li.
cave law dors not apply m an owner of property who builds or improves thereon,and
wM1a contracts for such pmjecu with a conuactorfs)licensed pursuant w the Convector's
License Law.
❑tem,x pt der,sea ,B&PCf this moon
Owner Date U
WORKER-SCO 4PE 'ATIONDECLARATI0
1 hemby Afars under penalty of perjury can of the following declarations:
1 how and will maintain a Cenificom ofCons,nno self-insure for Workers Compere
sation,es pmvidcd for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insunna,az myvimd by Section
3700 of the labor Code,for the lameamena of the work for which this permit is issued.
My Worker's Compensation Insurance caries and Polity number am:
Canner: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This Auction need not M completed lithe rcwit is for one hundmd dollars(5100)
or less.)
i certify Nat in the performance of theaga
ssyymk for which Nis permit is issued.I shall net
employ any person in any maoun W, .6r subjyCtmtMWorkesi Compervsation
Laws of California.Da
Applicant f�a i�ng Ms /
NOTICE TO APo the o r este of Exemption,you should
became Subject y the Woh po Compemmion provisions or the tabor Code.you mon
.,,Z forthwith comply with such pmvisiem or this Permit hall be deemed rooked. -
Z O CONSTRUCTION LENDING AGENCY
[-� I hereby writ that them is a eanuuctinn In ding agency for the perfumunce of
<Yi 7 the work fur which this permit is issued(Sec.3097,Civ.C.)
W Lender's Name
4' LeMIM's Address
D Z
U Q 1 certify that 1 have mad this application and sale that the above information is
LL. F corecr,I agree 0 comply with all city and county indicators and soon laws relating to
0 building consuucdon,and hereby authorise mpresenutives of this city no enar upon the
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ahovl-mcmidgin property for inspection Whichpurposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
H Z incoide;judgments.he graming Of thissesmit, may in any way accrue agwnn said City
U z A APPLICANT
of thegrantingof this permit
'-^ APPLICANT UNDERSTANS 1�N�D,�S AND WILL COMPLY WITH ALL NON-POINT Issued by: DateSM C
signature ol`�ppL VOConvut r \, Data
/
-I ° Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom or handle havallous mMoiel
As defined by the Cumnino Municipal Code.Chapter 9.12,and the Health and Safety
'AgEWL.rk,16"7.255320?
❑Yes 0N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future buildingacupant use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it W—dous-itoonummants as dcfncd by the Bay Ama Air Quality Management all new materials for inspection.
District?
C Yes 0N
1 have mad On hou mous maanals requimmenu under Chapter 6.95 of the Califor-
nia Health&SwmyCod,,sccdom 25X15.25533and 25534.I undersand Xao if the building
Jas n9Lcp only have a aunt,Net it is my rspomihility m notify the aeup.,of the
mquirEmcn !, et he am,pnoreisauanaofaccnifeaa�ranpaney. Signature of Applicant Date
1 � �i
Owner mwhmih , Date All roof coverings to be Class"B"or better
Community Development
r 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JOB/ADD E S: 1 /` q PERMIT #
��b1S k � l � ck Pit(03 CSI lSut�- 01,�d 2-03 �—'
OWNER'S N L ; PHONE # z�w - —�
GENERAL CONTRACTOR: 76Y u 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 47
1
z , Q o �
Owner/Contractor Signature Date
CITY OF CUPERTINO
S-01 TEMP POWER
SCITY OF
CUPERTINO PERMIT APPLICATION FORM
APN # 5_ Z� oma' - Date-
Building Address:
Owner's Name: Phone #:
L ��, 40g -91 - 4
Contractor: I ' Phone: License #:
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Y too
Contact: (� Phone:- Cupertino Business License#:
Building Permit Info:
Elect P- �II{ Ay CA17U
Job Description:
Residential Commercial ❑
Cost of Project:
� D00 Ob
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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