03090127 (2) CITY OF CUPER'1'INO
BUILDING DIVISION PERMIT CONTRAGTMINFUWATION
BUILDING ADDRESS: DEBCOR PERMIT N003090127
OWNER'S NAME: 1358 S STELLING RD PERMIT ISSUE DATE
3
NG: SANITARY N0, CONTROL NO,
ARCHITECT/ENGINEER: BUILpINLEG PERMRINFO
BLDG ECT PLUMB MECH
100 L.that IDCONTRd once, DECLARATION
of ION Job Description
EE 1 hereby affirm That 1 am licensed under provisions ofs Code, 9(commencing p
with Section 7gk))of Division 3oftW Business and Pmfcwinm Code,and mylicense is
a in full force and e
i req? License class Lle,a TEMP PWR POLE .�
�r Dam Contractor
ARCHITECTS DECLARATION
f60
I understand my plans shall be used as public records
e o G Licensed Professional O
OWNER-BUILDER DECLARATION a�
I hereby affirm that I am exempt from the Contractor's License Law(or the v
000 following mwon.(Scedim 7031.5.Business and Profcuiom Code:Any city or county (�
�m l< which rectums a permit to construct,alter,improve,demolish,or repair any structure c
26 prior Bs its issuance,alsomquirm the ayplicint(or such pennitm plc a signednalement
cr thuhcisliccnscJpursuanunthcProvisinmofthcCanwcmr'sliccnsclsw(Chapur9 Sq. Ft. Floor Area Valuation
Z�S (commencing with Section 7000)of Division 3 of the Business and Ptnfessinns Codc)or
su, that he is commit therefrom end Ne basis for the alleged ezempdon.Any violation of 36617105 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil actually of APN Number OCCU anc T e
- not more than five hundred dollars(5500). - - -- P Y- YP ---- -
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,end the awnum is not intended or.lferet for Set.(See 7094,Business U
and Professions Code:The Comactorm s License Law does not apply an owner of 304 - ROUGH EeL TRnl L:ALODS -
property who builds or improves thereon,and who does such work himself or through his
own employers,provided that such improvements.not intended or ofcmd for ala IL
howevar.the building or improvement is sold within one year of completion,the owners
builder will have the burden o(proving Nat be did not Wild or improve for purpose of
sale.).
❑ h as owner of the pmpeny,am exclusively contracting with licensed contractors to - - - -
construct the pmj¢s(Sec.7(144,Business and Professions Code:)The Contractor's Li.
cense law does not apply to an owner o(propcny who Wilda or improves Innocent,and,
who contours for such projects with a contracmr(a)licensed purvism to the Contractors
LV¢Inse Law. n
ll.tem eae� 1`P ee. ,B&PCfor bite re on
I /7wnar m
WORKER'S COMPENSATION DECLARAT --
Iberebya(firm ry under penalty of perjuroe of the owing declarations:
I have and will maintain a Cmi fornm of Consent to self-insum for Wortrr's Compcm
sation,u provided for by Section 37M of the LaWf Code.for the perfarmancc of the _
work for which this permit is issued. -
1 have and will maintain Worker's Compensation Insurance,as required by Section -
J]Ofl of the Labor Code,for the performance of the work for which Niss
is permit is ued.
My Worker's Com ruination Insurance carrier and Policy number arc:
Cartier, Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection readout becomplesd If the permil u forone hundred dollars(f I)O)
or Ices,)
1 certify,ton in the pc,f iorence of the work for which his permit is issued.I shall nut
employ any person in any manner an as to become subject o IW Workeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Lahor Code,you must
O forthwith comply with such provisions or this farm it shall W deemed revoked.
fn CONSTRUCTION LENDING AGENCY
1 hembj affirm hat there is a eomtruction lending agency fm lbe performance of
Y the work for which this permit is issued(Sec.3M,Civ,C.1
J C) Lender' Name
1 Lenders Address
::) Q I certify that 1 have read this application and sure that the aWrc information is
y F correct.1&&rte to comply with all city and county ordinances and ass laws relating to
0 t.) building construction,and hereby authorise representatives of this city to enter upon the
6Wi above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
:r h liabilities,judgments,cess and capcnsca which may in any way accmc against Said City
in consequence of the granting of this Permit,
r7 APPLICANT UN ERSTANDS AJ4D WILL COMPLY WITH ALL N NPOINT Issued by: Date
SOUR ATIONS.
�� Re-roofs
Signator fAppIu,oVContracmr m
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle havardous material
a defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? �N. All roofs shall be inspected prior to any roofing material being installed.
cam the appli ant err mtare baimingoedapam a egaipmemrraevmea whish If a root is installed without first obtaining an inspection,I agree to remove
It Aaemduus air 2ammot's s es defined by the Bay Area Air Quality Management all new materials for inspection.
one't
❑YesNu
I have mail the Una cmsmasrialsmquimmenuunder ,Chapter6.95ofds Califon
ria Hcalh&Safety Code.S cwm25S05.25533 end25534,1undersundthniftbe Wilding
o
does no,c nu a snap¢ 'it is my res'namility m outsIW
noply It pent n(
require c It ustbe e 'orwissuancerfaccnie.to r apart . Signature of Applicant Date
13
te
Gwnere .rri,edagent Date All roof coverings to be Class "B"or better
-"� CITY OF CUPERTINOS3 p2
TEMP POWER o z
UP TY OF PERMIT APPLICATION FORM 3 /
APN# 36& —/7— 1015- . Date:
Building%d
o . TEZC/Avb
Owner's NamePhone#:
Contractor:
d OJ Al c2 Phone: License#:
ti
Contact: Phone: Cupertino Business License#:
icN��eo -39
Building Permit Info:
Elect ❑
Job Description: �— Q
/E/�P �u12 / d�E
Residential ] Commercial ❑
Cost of Project: 2900
Qty f
A ca le Fee ID Fee Description FeeGrou
BTEMP Tempo Power ELECTRICAL
EPER MEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
o�
Z3 � 3-
)93 ,