07010146 CITX OF CUPERTINO C�INTRAf=TSR
-BUILDINk:DIVISION PERMIT PERMIT NO.
BUILDING ADDRESS:
TE
OWNER'S NAME: 01 2-1 /-)nn-7
TONY BAIG SANITARY NO. CONTROL NO.
.)NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
p zo LICENSED CONTRACTOR'S DECLARATION Job DOSCflptlOn
U P 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
e z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is TEMPORAM POWER POLE
a. in full force and effect.
v�z License Class Lic•$
p Date Contractor
9E-m ARCHITECTS DECLARATION
aa
< I understand my plans shall he used as public records
�yU
4 O y Licensed Professional
OWNER-BUILDER DECLARATION
�N 1 hereby affirm that 1 am exempt from the Contractors License Law for the
cc following mason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct.alter•improve,
demolish,or repair any structure Valuation
y'ti prior to its issuance,also requires the applicant for such permit to file a signed statement $ Ft.Floor Area $100 O O
?> that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
XF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of A N Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 37517008 .
v R
not more than rive hundred dollars(5500). v
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 sale(Sec.7044,Business
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
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
sate.).
L 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 contractors)licensed pursuant to the Contractor's
License Law. B&P C for this reason
C]1 am exempt under Sec,
Owner
1 Dare ,
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
0 1 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.
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 Compensation Insurance carrier and Policy number arc:
Cartier. Policy No.:
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 as to bernmt:subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:lf.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith 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
Q! r7 the work for which this permit is issued(Sec.3097,Civ.C.)
Lr]Q Lender's Name
0. (.enders Address
U 0 I certify that 1 have read this application and state that the above information is
[I, correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize 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
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b3:
SOURCE REGULATIONS.
Re-roofs
Signature ol'Applicanr/Con for Dare 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 roof: shall be inspected prior to any roofing material being installed.
0Yes '01N° If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment ordeviceswhich all new I materials for inspection.
emit hazardous air contaminants as defined by the Bay Area Air QualityManagement
District? yy��
Yes
.111 No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Codc,Sections 25505,25533 and 25534.1 understand that if the(wilding
does not currently have a tenant,that it is my responsibility to notify the occupant of the Date
requirements which must be met prior to issuance of a Certificate of Occupancy Signatur of Applicant
r" v All roof coverings to be Class"B"or better
Owner or aut zcd agent Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF
�UPEI�TINO Fax(408)777-3333
Building Department
JOB ADDRESS: S t,,.,t�n0�3_;2� . r PERMIT #
OWNER'S NAME: PHONE # �
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: >a. )- 2-3--c�4
Si nature Date
Please check applicable subcontractors and comF lete 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
Owner/Contractor Signature Date
CITY OF CUPERTINO 0 �
TEM P POWER
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN# 516— Date:
Building Address:
Owner's Name-,--.---- Phone #:
Contractor: Phone: License #:
V 3 ll
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑ �-� �;–. 'l f
Job Description:
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE El;ct. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING