03060092 (2) CITY OFCUPERTINO ` -'
BUILDING DIVISION PERMIT �C0NTRACT_,,6 NFUItMATION'
BUI LDING ADDRESS: DAVID LEU PERMIT NO 03060092
OWNER'S NAME: 10316 STERLING BLVD : . Plnehirt 'FgA712/2003
NE: SANITARY NO, l CONTROL NO.
ARCHITECVPNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
000 LICENSED CONTRACTOR'S DECLARATION
t 1 hereby of irre that 1 am licensed under previsions of Chapter 9(commencing Job Description
wOh Section 7000)of Division 3 of the Business and Professions Code.W my license is t {N� r1 +IPwp
e in full force and effect. tj"'U a V �r�Jf
qz LicenseamsLie, TEMP POWER POLE
Dau contractor
ARCHRECfS DECLARATION
1 understand my plans Nall he used as public records JUN 13 2003
k� Licensed Professional
OWNER-BUILDER R OEthe Com Ino BUILDING
I 1 hereby artirtn Nal 1 i. exempt from the Cssions o e:A nsc law for hK
p0 whfollich
greresa Permit i 7(DLS.Buafeas r,imp improve,
ore Code:Anyeihy or eaunry
IS which its requires•permit ra tires t e alar,impmvu,de ermit t fi repair any structure
ZS^ pdorm licausedpur onnit.reslhovishmsmtha Cchndemitm fcarele a Loed w(Clmmenl
(comm islicensed pSmtionwlhcpmvislonaof theto BSinsatin a oflimCudk)ur Sq.Ft. Floor Area bl�h0n
$
(commencingxerept Section T000)nf basis n3 trete Businetimd Pro Any Cnde)or
Nat he u esempl thme(rom W the basis for the alleged exemption Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a cb,I Penney of 3MD14gDfl3W00 Occupancy Type
not mom Nan five hundred dolt.(5]00).
❑I,u owner of Ne property,or my employes with wages rat their to compensation,
willdo Bmwork,and lestoomundi... U
— Ir -r Ins C GnS
and Prefosalona Code:The Contracur's Liceve Law does ani apply to an owner or 3 0 4 — ROUGH L''Ii C.:lTl R I A
property who Nd IM or improves thereon,end who data suc h work himsel f or through his
awn employes,provided Wit such improvements are not Intended m offered formal.If.
however.the building or improvement is mid within one year of campledon,the owner,
builder will have the burden of proving that he did not build or improve for purpose of
tile.)..
Xh u owner of the property,am excluively eonuacting with licensed contractors to
o wet the pmjat(Sec.70".Business and Profesalo m Code:)The Contractor's Lt.
cause law does not apply to an owner of propeny who builds or imProw Nemo.and.
who contracts for such project/with a cotrsemr(s)licensed pursuant in the Contracto's -
License law.
I am exempt and r Se _,B&PC for this mown
Owner Dau
73071WOMPENSATION DECLARATION
I hereby aRhm under penalty of perjury one of due fallowing dalantions:
I love and will mainuin a CeNRate of Consent to sertdnmm for Workers Coul
W
on,u provided for by Section 3700 of the labor Code,for the performance of the
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section
of Ne labor Code.for the performance of Ne work for which Nis permit is issued.
Workee,CumMmust o lesutwa carrier and Policy number arc:
rtier. Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS
COMPENSATION INSURANCE
ohls section nae Out be completed little permit isforone bundred dollos(SI00)
or)am)
1 certify Net in de,performance or the work for which this permit ls source,I shall not
employ any pcaon in my manner an u u became subject to the Workers Compeuation
Laws of Califomia.Dau
APPlitanl
NOTICE TO APPLICANT:If,atter making this Certificate or Exemption,you Mould
become subject to Ne Worker's Compensation provisions or the labor Cndo,you most
0 O faMwith comply with such provision or this Permit shall IN deemed mmked.
r r~NiCONSTRUCTION LENDING AGENCY
I heathy a1Rrm that Nem is a construction lending agency for the performance of
Sd> Nc work Pur which this permit is issued(Sec.3x197,Civ.C.) ,
Y Q under's Name
Lenders Address
U Q 1«nify that 1 have read this application W mute Nat the above irtimeo do is
:T.F canal.l agree m comply with all city and county ordinances and sum laws relating to
0U building construction.md hereby authorise representatives or Nis city to enter upon the
dabove-mentioned property car insr4cdon purposes. j
(We)agree m arse,indemnify and keep lurnom s the City or Cupertino against
r rA liabilities,judgments,costs and expenses which may in my way accrue against .to City
UZ in conmqucuce of Ne panting of this perouil.
^ APPLICANT UNOE� S�ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS
CA Re-roofs
algnnure of ApPlicananuamor Dau T ` �,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof ` / ` /V`_
Will the appupn ice future building occupant nom or hadith cahh anmaterial l ,
ti defined by the Cupenicto Muniripal Code.Gspter 9.13.and the HcaIN and Safety -
adc.Scmanasu(a>1
Y. ❑Nn All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or suture building=upon,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havrdnus air conuminants o defined by the Bay Area Air Quality Management all new materials for inspection.
District?
QYcs ❑No
I have mad the haardnus materials requiumenu under Chapter 6.93 of the Califor.
nlaHcolth&Sarcty Cade,&cdunsZM5,3s333md2553d.Iundcrsund Natifthe building
does not curemly hese a L Net It ls my mapomihility to no ily Nc aeupent of the
requiremenuwhich un t 'cru issuanecora CenlOcau or Occupancy. Signature Of Applicant Date
er or authorized agent Date All roof coverings to be Class"B" or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. All the work authorized by this permit
B. A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse si e)
Property Owner's Signature: Date: u
Job Address: O g J Permit# ��o0 J Z
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF CUPERTINO
Q 03
TEMP POWER `
SCUPEkTINO PERMIT APPLICATION FORM
APN# -7 2— ( / / Date:
Building Address: (�
S lid b �
Owner's Name: Phone#:'
bAvIt) �
Contractor: Phone: License#:
t7qutl� LLU Aol 11 k I Z I
Contact: Phone: Cupertino Business License#:
Building Permit Info:
r
Elect ❑
Job Description:
Residential Comme cial ❑
CostofProjec ��T
Qty. if
Applig'a-ble, Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
2213 6