07010059 777777777.,
CITY OF CUpERTINO h
BUILDING DIVISION PERMIT � R� T�R
PERMIT NO.
BUILDING ADDRESS:
10571 JOHNSON AVE NAT IONPL
PERMIT ZSUE DATE
OWNER'S NAME: DcrTmrT c
RICHARD HORTON 1355 FILIPE AVE 01/09/2007
SANITARY NO. CONTROL NO.
'NE: (818) 221-6057
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
j O p LICENSED CONTRACTOR'S DECLARATION Job Description
e m(= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
=z w with Scction 7000)of Division 3 of Ute Business and Professions Code,and my license is TEMP POWER POLE
y in full force and effect.
D12z License Class Lic.o CONTRACTOR: LUCKY PORTABLE SERVICES
in Date I—=Contractor
X �� ARCHITECTS DECLA A ION
X U 1 understand my plans shall be used as public records
4.a
H Licensed Professional
n y 3
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
i o o following reason.(Section 703 1.5,Business and Professions Code:Any city or county
K m which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior w its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $135
yF (commencing with Section 7000)of Division 3 of Ute Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 7 5 2 7 0 0 9 .�ff Number Occupancy Type
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044.Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
awn 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.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury we of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I 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 Compensation Insura cc carrier and Policy number are:
Cartier Policy No.:41*A6 0 2 6 Z
CERTIFICATE 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,I 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
�Z forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
F~t CA) 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
aLender's Address
U 1 certify that I have read this application and stale that the above information is
IL" cored.1 agree to comply with all city and county ordinances and state laws relating to
Q U building construction,and hereby authorise representatives of this city to enter upon the
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
V Z in consequence of the granting of this permit. Date
-4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULAT)ONS.
-� _... /_ el-O Z- Re-roofs
SignattueofApplican r Da1C T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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 Safety
Code.Section 25532(a)? All roo's shall be inspected prior to any roofing material being installed.
❑Yes 1C_I No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu 9
I have read the hazardous materials requirements under Chapter 6.95 of the Califor- �/I I
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building f T
does not currently have a tenant,that it ism responsibility to notify the occupant of the
requiremcn wh' h must be met pri man f a Certificate of occupancy. Signature of Ap 'cant Date
M
41- All roof coverings to be Class"B"or better
Owner or authorized agent Date
Community Development
10300 Torre Avenue
fi
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
rUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
O 7 ( So 4 res� 4&/ - "7 Z) U S"
OWNER'S NAME: /;:-::f IPHONE # yah `7'?2 y �6
GENERAL CONTRACTOR:pZ FAX# d �f J
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSI14ESS 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
/'Z' ��� � /-
Contractor Signature Date
CITY OF CUPERTINO
TE,W POWE
OF
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Ow er's Name* Phone #:
a-, r- /_ rv-
Contractor: NOM19Phone: License#:
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Contact: Phone: Cupertino Business License#:
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Building Permit Info:
Elect lel
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