03090132 (2) CITY OF CUPEB't'INO 'A?3k
suu.DlNc DlvlsloN PERMIT �GONTRAC�`TQR INFORMATION, .;',
eu1LOlNc ADDRESS: ARGON CONSTRUCTION PERMIT r+o03090132
OWNER'S NAME: 16080 CAPUTO DR. ##100. PERMITISSUEDATE
NE: (408) 778-6835 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION Jab Description
E U 1 hereby affirm Nal 1 am licensed under provisions of Chapter 9(commencing p
with Section IXX))of Division 3 of be Business and Profcasiom Code.and my license is
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in Oil
dart«t. Q Ugpe 2 TEMP POWER POLE
t-V�V1Z Liccn C10
aF Datc Cunu
A ON
qq ARCHITECT' AR
f 2 1 understand my plans shall W used as public rernrds
)y0
.0 Licensed Professional
OWNER-BUILDER DECLARATION
COf I masaereby erfipmon 1 L exempt from Cssions Co :AnycLaw furtW
OO following reason, etch t 703 nt, Business and Professions Code:Any city or county
5$"t which its unaapermit recnnstmai,alcor,improve t for s�h Perlia me repair any sbuenn
_i< Potreo its issuance.also.,to the theapplicantthe Car.%.,',u Rlesigned stanmem
¢ that he ening sed Purstion7 )of Division 3 of the 8 uumr'snd Professions
(Chapm9 Sq. F[. Floor Area Valuation
bit(cohe is examwith Section7")And t f Division r the
the B ed axe and on.Any
violaodc)or
the(he is exempt therefrom roti the hoes for the alleged exemption.Any vtomdan of 32637027 . 00
Section 7031.5 by any applicant far a permit subjection,enillewa Io a civil penally of _ APN Number .. - Occu ane e
not mora Iran fie hundred dollars MOO). - -- - - - P Y Type
----
I,as owner More property,m my cmployce with wages as their sole compensation,
will do the work.and the swclum is not intended moffmad fanafe(Sec.7W.Balloons. _ �
and Professions Code:The Contractor's Liccnu es Law donot apply to an owner of 3 O4 - ROUGH ELECTRICAL
uired Inspections
property who builds or improve thereon,and who does such work himself orthrough his
own employees,provided that such improwmcnta we not intended or offered ferule.iL
however.Ne building or improvement is said within one yew of completion,the owner.
builder will ban the human of proving that he did not Wild or improve for purpose of
exam].
I,as Owner of the property,am exclusively contracting wit licensed contractors to -
wasuuet the pmjccl(Sec.7044,Business and Pmfessiona Code:)The Comswtoh Li.
cone law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a commnor(s)licensed pursuant to the Complaint's
License law.
❑ 1 om exempt under Sec. B As P C for his moon —
Owner Dote
WORKER'S COMPENSATION DECLARATION
1 hereby allure under penalty of perjury one of the following deelerations:
1 hate and will maintain a Certificate of Consentto self-imum for Workers Compere
'oom,m provided for by Section 3]00 of the later Cade.for the performance of the
wo ,for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which thia Permit is Issued.
My Workers CnmPemadon lnsun.nlaI artier a�ndvpplicy number en:
Came' S��tT/^ NQ Mlicy No.:
CEQTIFICATE OF EXEMPTION FROM WORK ERS'
COMPENSATION INSURANCE
(This section need not W completed if IW Permit Is for one hundred dollass($100)
ass.)
1 certify that in the performance of the work for which this Permit is isms d,I shall not
employ any Nixon in any manner in as In become subject o the Work ar Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject to the Woher's ComPcwtion provisions of tW labor Code,you must
� z forthwith comply with such provisions or this Permit shall W deemed ranked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency tar he Performance of
Y, 7 the work fur which this permit Is issued(Sec.369],Civ.C.)
4 Q Lenders Name
3 z Lenders Address
Q 1 certify that I have read this application and soon that the above information is
y F comet.1 agree to comply with all city and county ordinances and state laws relating to
'U building construction.And hereby authorise reprexntatiwa of this city to enter upon the _
4 abow-mentioned property for inspection purposes.
r (We)agree to save,indcmni fy and keep harmless the City of Cupertino against
N liabilities,judgment,coats and cxMmcs which may in any way acerae against mid City
in
consequence or the granting of
J z APPLICANT UNDERSTANDS tASDrWILL COMPLY WITH ALL NON-POINT Issued by: Date
rSaad..
GULATI
Re-roofs
pidermUContracmr Data
HAZARDOUS MATERIAIS DISCLO URE Type of Roof
e applicant or future building occupant or handle hazardous material
the Cupertino Municipal Code,Chapter 9.12.and the Health end Safety
25532(x)? a6� All roofs shall be inspected prior to any roofing material ling installed.
rl e applicant or future Wilding ottvpant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
u air contaminants o defined by the Bay Area Air Ouality Management all new materials for inspection.
/
❑Ycs LIQ s.
I have mal the haxamnus materials requirements under Chapter 6.95 of the Califor.
nixHealth&Safny Cate.Sadum25505,25533and]5534,IundcrsundthwifoW Wilding
does not eunendy haw a to 0 the io is my ms mobility m notify the asupam of the
myvimm which must m Poor sae ora Ccroifinn\QcuponcyJ� Signature of Applicant Date
(' / „B All roof coverings to be Class"B" or better
O authori'rcd agent Date
CITY OF CUPERTINO
TEMP POWER 0 301�3 Z
UPERTINO PERMIT APPLICATION FORM
APN # Date: r� /7/613
Building Address:
/O.1610
Owner's Name: Phone #:
IG. nn AV✓
/Ou 73.7- 1577
Contractor: Phone: License #:
Contact: Phone: Cupertino Business License#:
u -.2�� - �/2lZ
Buildipy,Permit Info:
Ele t
Jo escription� d rK
rmor�L'- I � 2 �-�tpe'rFv puwe�- � o�e hp� e
Residential-4—
esidential Commercial ❑
Cost of Project:
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ty
AQale Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMTfFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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