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03100146 (2) CITY OF CUPEBTINO BUILDING DIVISION PERMIT i CONTRACTInR INFORMATION BUILDING ADDRESS: PERMIT N0.03100146 3100146 OW NF.R'S NAME: PERMIT ISSUE DATE NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INTO BLDG ELECT PLUMB MECH I00 LICENSED CONTRACTOR'S DECLARATION u I home,affirm cher l am lintroad ider provisions of Chapter 9(cmaomo ring Job Description ;¢ with Scoion) poi Division Sof the Bunneu end Profcuiuns Code.endo nm is .�< ; m; tfr . TEMP POWER Ola? GA. IrS1"' Lle.x Dam rYw camronnr ^ CONTRACTOR: BAY BUILDERS (10/20/03) Isqq' ARCHITECT R ION i d U 1 u land my plant shall M used u puhlic records / .WS Licensed Professional ) OWNER-BUILDER DECLARATION / )<8 I hereby affirm that I am esempl form Use Contractor's License Lew for the ❑o following assns(Sccdun 119:.5,Business and Profeuions Code:Any city or county 1$ which requires a permit to consumer,alter,improve,demolish,or repair any structure 1Ly6prior to its issuance,also requires the applicant for such Knelt to file a signed statement m that he is licensedpursuanuntheprovisions(iftheContractnhLiccnsclaw(Chapter9 Sq. Ft.Floor Area Valuatio$500 21-$ (commencing with Section 7(100)of Division 3o the Business and Professions Code)or On he u uempl therefrom end Nssa e hfor Ne uIcgcd exemption.Any violation or Section]WI.5 by any epplicantfor a Permit subjects the applicant to a civil penalty of 37LSNi$llttbbCr00 Occupancy Type not moa Nan five hundred halls..($500). ❑T.u owner of the prepeny,or my employees with wages As their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.]044,Business Required Inspections and Professions Code:The Cormier.,. Cr's License law does not apply to an owner of q P property who build,or improves themon,and who doessuch work himself or through his own employees,pmvidcd that such improvements arc not intended or offered for sale.If, however,Be building or improvement i,sold within one year of completion,the owner builder will have the burden of proving inn he did not build or Improw for purpose of MIs.), ❑1,as owner of the propeny,am cwlusively contracting with licensed comments to continuer the pmjcct(Sec.7004,Business and Potassium Code:)no Convenor's Li come law does not apply to an owner of property who builds or improves themon,and who contracts for such projects with a convaaods)licensed pursuant to the Convector'& License law: I am emmpt under Sec. ,8&P C for this..an Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby a(Brm under penalty of perjury one of the following declantines: I have and it:maimalA a Cenlficate of Consent to sel6insure for worker's Compcn- 130 on,u provided for by Section 37M of the Labor Code.for the performance of the rk for which this permit is issued. I ban end will maintain Workers Compensation Insurance,u aqutrtd by Secdon gfJaa labor Code,for Ne perfomtmce of the wqk trarwhich this permit is issued. Her Crmpemetion lnsunna cemicnndP umherart: tier:$-sr,-F�,.�y��tYT t� Policy Nod '- CERTIFI ATEOFEKEMPTION FROM WO KERS' COMPENSATION INSURANCE (Thissectirn Used oat he complemd if the permit is for one Aundrtd dollen(51(kp or less.) I certify Nat in the performance of the work for which this Permit is issued.I shell not employ any penton in any meaner an As to become subject o Use Worker:Compensation Laws of California.Date NOTICE NOTICE TO APPLICANT:If.Compensation making this Cenincete the Exemption,you should became h,compy the Worker's Coons or is provit shu of the Lehrer Code,you must D,z foMwith comply with such provisions or this permit be deemed revoked. QCONSTRUCTION LENDING AGENCY 1 herehy.Runt Out there iso construction lending agency Ins the perfurmance of Yd> Ne work for which this permit Is issued(Sec.3097.Civ.C.) 4o Lenders Name 3 z Lender:Address ..)O 1 minify that I have read Nis application and see¢mer the @bow information is i F correct.I agree to comply with LI city and county ordinances and sate laws relating to D V building eon&vection,and hereby authorin,mpretentsaws of Nis city to enter upon IN Na 'hove-mentioned pmKrty for inspection purposes. (We)agree Ir save,indemnify and keep harmless the City of Cupertinoagainst yy liabilities,judgments,costs and expenses which may in anyway same Against Mid Ctry in J ^ APPLICANThis Permit. consequence UNDERSTANDS of the granting of tAND WILL COMPLY WITH ALL NON.POINT Issued by: Date rREGULATIONS.GULATIONS. Re-roofs APPIianU n or Dem RDme b MATERIALS DISCLOSURE Type Of ROOF e a Cupert or furore buildingoccupantnos or handle HeaNuus d Safer l me Cupertino Municipal Code.Chapmr 9.12,and the Hcahh end safety n ns32(aY! NAll roofs shall be ins ected rior to an roofin material bei.. installed. s �Nr P P Y Pa ghe applicant of future building Occupant use equipment or devices which If aroof is installed without first obtaining an inspection,I agree to remove m air cortmothis ts u cfined by the Bay Arca Air Quality Management alI new materials for inspection. ❑Yes I have mad the husaNnus materials reyvimments under Chapmr fi.95 of the Califon nia Hcalth&Safcty Codc,Sections 255(15,35533 erJ 25534.1 understand diatribe building does not cunernly have a tenant,that it is my responsibility to notify the occupant of me requirements which must be met prior to issuance of aenileam of ore rpanmy. Signature of Applicant Date l0 O All roof coverings to be Class"B"or better cr ar o..da6 Dom Q CITY OF CUPERTINO k CQ TEMP POWER op UPERTINO PERMIT APPLICATION FORM APN# `7 5�-0 g 0 1 R , Date: 10/2-0 /03 Building Address: I 33 —vcti Owner's Name: Phone #: Contractor: hone: _66 License#: 6 3 7 Contact: hone: Cu ertino Business License#: I C� e� fs 6�s 56� 3 CU ��C d t O©fig Building Permit Info: Elect Lld Job Description: G "` Residential ommerci ❑ Cost of Project: 2Qt ,if li able Fee ID Fee Description Fee Group BTEMP Temporary Power ELECTRICAL EPERMITFEE Elect. Permit Issuance ELECTRICAL BUSLIC Business License BUILDING