03080157 (2) CITY OF CUPER'CINO
BUILDING DIVISION PERMIT aCONTRACTnR=INFORMATION:'
BUILDING ADDRESS: _ K & M DEVELOPMENT INC PERMIT"03080157
' OW NER'S NAME: 1060 WEST HILL CT PERMIT ISSUE DATE
NE: SANITARY 0. CONTROL NO.
(408) 253-9787
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
!00 LICENSED CONTRACTOR'S DECLARATION
£ I hereby affirm that I am licensed under p na of chapter 9(commencing Job Description
s� with Sution](MMy fpi ision Sal NC Business andly�cssinm Codc.a dmyl ccnm is
mmu rnroygddarrem l � /�1t� TEMP POWER SERVICE
Littnu Lica
Dal Cunt v
e' ARCHITECTS DEC ON
C lune and my fans shall W used as publieceords
>yU
C Licensed Pmressinnel
OWNER—BUILDER DECLARATION
Mq I hereby arrrm nhsn I opt exempt from the Contractor's License Lew Tor the
p O following mason.(Seedun 7131.5,Busines..ad Professions Code:Any city or county
3 a�i which requires a permit to Conswct,eller,improv,demolish,or repair any swnum erzrin
-Zi prior to its issuance.also requima the applicant for uch Pcsmitto file a signed Statement
Bm0 that he is licensed Pursuant in the provision of the Contractor's Limnse Law(Chapter 9 Sq.Ft. Floor Area Valuation
it (commencing with Section 70p)of Division 3 of the B usincm and Profcasinna Code)or
3
at N is exempt therefrom and the hues for be alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of - AFN Number. Occupancy Type---
will
e___
not more than Eve hundred dollars(S500). "' '—'"" '-' -" ' "'- p y yp
❑Laownor of the propertyor mycmployeea withwred for ak,(Se.044.Business
willdothusid.and the IC itureC.musnots License
Law dos ntapplytoaa,Business . 103 — UFER Required Inspections
and Profession Cade:Tim ves co cmrs Littre obs does not apply lf rt owner is
Own ertywbo b,provi improwsch improvements
and who doesaud tendo himselfor his 304 — ROUGH ELECTRICAL
own employees,provided tint such impmwments are not intended Completion,
for CoIeJL
builder ,the building or improvementissold didnone year or marrow
the owners
builder will have the burden of proving that be did not Wild or improve for purpose of
❑1,as owner,of ON property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Profusion Cade:)TO,Contractor's Li.
ccnm Taw does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with s contractor(s)licensed pursuant in the Contractors
License Law. '
❑I am exempt under Sea ,B&P C for this mason -
Owner Date
WORKER'S COMPENSATION DECLARATION - ...
1 hereby affirm unJer penally of perjury one of the following declarations:
I have and will nommain a Cmdreate or Consenuo ulf-insum for Worker's Compcm
13710'0
on,u pmvided for by Sce,tion 3]00 of the Labor Code,for the performance of tW
h for which this fruit is issued.
1 ban and will maintain Worker'sCompenNon Insurance,as required by Section
of Ne Labor Code,for the performance of um work for which this permit is issued.
rke' m }anon lnsumrmcc ern Policy numberam: `7
icy No.: /533 r .
"R IFICATE OF EXE ION FROM WORKERS' Or
COMPENSATION INSURANCE
(This section need not IN completed if tie Permit Is forone hundred dollars(SIM)
less)
1 candy that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manncrm as to become subject o the Workca'Compdnsation
Laws of California.Data
Applicant .
NOTICE TO APPLICANT:If.after making this Ccnireatc of Eacmpion,you should
become subject to the Workers Compensation provisions of the Labor Code,you most
Z forthwith comply with such provisions or this permit nall he deemed revoked,
Z O CONSfRUC tON LENDING AGENCY
1 hemby,all m that there is a construction lending agency for the performaso or
Ya > Ne work for which thH permit is issued(Sec.309].Civ.C.)
YQ Lender's Name
reml
D z Ld tier's Address
J Q I certify than I have read thisapplication
and coup and sure that the above informationsfisng is k
y F building 1 agree no comply with y city and county ntatnancns and state laws relating he
7rJ Wildinmction,and hembyauthon purpoeumetivcs of this city to enter upon the
W
move-mentioned(We)agree
to samroperty for inpcetian kePwses.
(We)agree to Cove,indemnify and keep hay in m the City of Cupertino against
liabilities,judgments.of
gatsand oapcnseawhich may in any way attmcapinss aid City
;J Aconsequence of UNDERSTANDS
this permit. yb 7
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RECUL
4 O Re-roofs
nature of or Due
A n US ATERIALS DISCLOSURE Type of Roof
Will the applies r wilding occupant store or handle haardous materiel
a defined by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
GWC,Section 25513(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yso
Win the applicant or future building Occupant use equipment Ofdevicea whlcn If a roof is installed without first obtaining an inspection,I agree to remove
it humdnua air c.ammiNots a dcrnd by the Bay Area Air Quart'Mana.Com m - all new materials for inspection. '
strict?
Dyes C*
P have read the haaNn���u tmaaterials requirements under Chapter 6.95 ofthe Califon
niaHealth&SofctyCodc.Sx4mu25505.25533u 25534,1underu ftif,k Wilding
it=not currently haw a tena4 Nat in be my MSNMhility an notify IN occupant of the
reyuiremcnu which a men pnonu iss cofa CcniEcate of OccuWprya y� S ignature of Applicant Date
onzeJa D e All roof coverings to be Class "B" or better
,� CITY OF CUPERTINO
TEMP POWER
ICUPEkTINO PERMIT APPLICATION FORM
APN# S-42 - 16 . 03 4 Date:
d-` z 7&3
Building Address:
lo66n � Luc<� Rte.
Owner's Name: Phone#: 3
cf/r�.,✓C /a^�r+ �v�'- 729.. '
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect 0
Job escription:
Residential 0 Co ercial FJ
Cost of Project`:
Qty
A ica e Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
� as 9z 9