The URL can be used to link to this page

07010054 CITY OF CUPERTINO C�l�`+t�RAt +ORIt?RI�ITI�Nr 2UILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 21926 DOLORES AVE NICE & R PERMIT ISSUE DATE OWNER'S NAME: _r 7170 01/09/2007 CINDY HSU 10663 SANTA LUCIA RD SANITARY NO. CONTROL NO. .ONE: (408) 861-.0928 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB J O Q LICENSED CONTRACTOR'S DECLARATION lob Description e,-,tI hereby affirm that I am licensed under provisions of Chapter 9(commencing TEMPORARY POWER POLE c Z m with Section 70 00)of Division 3 of the Business and Professions Cod..and my license is INSTALL H in full force and effect. v�Z LicenClas se •8 3 t—; Date Contractor ARCHITECTS DECLARATION 0.< l understand my plans shall be used as public records �4V u.y Licensed Professional n y OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor s License Law for the 00 following reason-(Section 7031.5,Business and Professions Code:Any city or county .40 9 which requires a permit to construct.alter,improv..demolish,or repair any structure Valuation Za prior w its issuance,also requires the applicant for such permit to rile a signed statement `q•Ft.Floor Area $200 < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 yF (commencing with Section 7000)n(Division 3 of the Business and Professions Code)or y 9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of APA Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 357140 15 . V V not more than five hundred dollars(S500). ❑1,as owner of the property,or my employees with wages as their sole compensation, Required Inspections will do the work,and the structure is not intended or offered for sad(Sec.7044,Business and Professions Code:The Contractor's License Law docs tint apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If. however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. B&P C for this reason ❑1 am exempt under Sec. Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Workces Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work 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 this permit is issued. My Worker's amptmsati00 psuranc earticr and Policy number are: Cartier Policy No.: W:106119 CERTIFI TE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date— Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ',L forthwith comply with such provisions or this permit shall be deemed revoked. Z� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of (>y> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name 04 Lender's Address 1 certify that I have read this application and state that the above information is LUL" correct-I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the C)V above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may in any way accrue against said City in consequence of the granting of this permit Date V rz-h APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b C. SOURC E.REGULATI 0 S. b rRe-roof!Sign re of ApplidCon Doth LZoof H 5 MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safetycode,Section 25532(a)? i shall be inspected prior to any roofing material being installed. ❑Yes No I agree to remove Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes �Nu I have read the ha7ardt s materials requirements under Chapter 6.95 of thc Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify IM occupant Of the Date requirements which must be met prior to issuance of a Certificate of OC pan Signatu-e of Applicant l � D at All roof coverings to be Class"B"or better Ow authorized agent Datc. Community Development 10300 Torre Avenue • ,�:., Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 "UPEkTINO Building Department JOB AD KESS: PERMIT # ( Z &-e . t ' � 6 `7b�D& -C Y OWNER'S NAME: S PHONE # GENERAL CONTRACTOR: AX # I am not using any subcontractors: . Si ipatur Date Please check applicable subcontractors and com Clete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile cl ;a _ �Z, G er/Contracto ature Date s CITY OF CUPERTINO TEM F' POWER CUPE OF PERMIT APPLICATION FORM APN# � Date: /� n 7 � Building Address: rill— Owner's Name: Phone #: S —0 z Contractor: Phone: License#: Contact: Phone: Cupertino Business License#: — 2 Building Pef6t Into: Elect Job Description: Residential Commercial ❑ Cost of Project: Qty. if Applicable Fee ID Fee Description Fee Group BTEMP Temporary Power ELECTRICAL EPERMITFEE Elect. Permit Issuance ELECTRICAL BUSLIC Business License BUILDING