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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
10420 BURR RF)
TRT) TO BF, T)FTFRMTNFT)
PERMIT NO.
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OWNER'S NAME:
PERMIT ISSUE DATE
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CONTROL NO.
ARCHI]ECrtENGINEER:
BUILDING PERMtr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
.
Job D tl
Description
Chapter 9 (commencing
1 hereby affirm dial l am limmcd under Provisions of C
with Section 70M) of Division 3 ofthe Business and Profnsaons Code. and my license is
infnlltmccand + l
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TRICECTOR CYLINDER ANTENNA IN NEW LIGHTSTNDRD& 1
Lkcnse CI s - Lm.' 3
Dam Contractor
BATT CABNT&RATIO CABNET ON NEW SLAB -TRASH
Inde m AasCMH1SdDECLARATION
ENCLOSURE 192'
Licensed slcsa
OWNER -BUILDER DECLARATION
1 hcmby nlfrm that 1 ucmpt from the Contractors Law for the
:Anse
o 1. Business, and ons Code: Any city of county
following muon. (Section ]
onsom m, de or repair my
a(IC(11111 recnMWelaper,mforinh
permit. edeWLWR
prim its a IM+isionsof for such permit to file signed atatemml
prior b its issuance,
Ft. Floor Area
Valuation
Im rs nt to Mc re
pursuant to Mc provisions oftheMe and
Sq.
(man
Prmlaw(C Code) Or
BusinessviCodons
commencing with roflW Busirossand
]0nd
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thesui.
the bonds f on. My
Thu W u exempt therefrom and IW haste for de aleBW esemptiao. Any violation of
Met he is exempt
APN Number
Occupancy Type
said. 1031.5 by ally applicant form Permit mbje is the applicant.,+lull penalty of
not more than fim hundred dollars ($500).
35720038.00
❑ 1.+a owner ordie laavmy, m car wvloyeer cath wage, u Welt mm evmpensaden.
Required Inspections
will do die Pork and the structure 4 not Ntanded or offered for wale (Sm. ]pid, BULKse
more Pmfesaore, Code: The Conuxmis License Thaw dun non apply he an owner of
propertywho Wilds aimprems thereon, andwhodousueh wrokhim unif or Mmu8b his
own cmployres, psavldcd Nat inch imp ommus arc not intended rooffeed fmwla It.
however, Ne Wilding or improvement usold within am year of oompletion, the nwner-
builder will have die Wrdm of proving Nat he did net Wild or improv, for purpose of
nle.).
0 1, as Osamr of Ne prop,ny .m smmmumly connecting with licemed mntrmmsa he
oonstmct the project (Sm. 7054, Business and Professions Code:) TW Conuxmri Li.
cane Law docs not apply in an Owner of property who Wilds m improv thenen, and
who contracts for such pro$cs with a conuator(s) licensed purmant In de Conh1xcMes
License Law.
❑ 1 oro exempt under Sec . 8 & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declandoes:
]him and will maintain a Certificate of Comer t to self -insure fm Worker'sCmnpen-
f
sae.. u provided for by Seeti.n 3700 of Ne labor Code, for the pert..... of the
wart for hthW permit is ist
pave and will maintain Workers Compensation Insurance, u required by Section
370Oof the IaWr Guam. for the performance ofde work forwhiN min permit is issued.
'
My Warlmem Compensation (some ice came and Policy number are:
Carrier. C-ra.-r Policy No.: �/!M? i
CFIn1FlGTEOF EMMONFROMWORKERS'
COMPENSATION INSURANCE
(ThisseNen Iced nothecompk¢d if the per eft is froom hulreRredellan ($100)
ro kat)
I certify Wet in the performance of tie .,it for which this Permit is issued. I seal rot
employ any person In any mMnerm as to become subject to We Wmkers'L'ompernah .
Laws of California Dam
-
Applicant
NOTICE TO APPLICANT: IC after making this Certificate or Exemption, you Mould
become subject b the Workers Compensation provisions of IW Labor Code you most
' foMwith comply with such Proviaiom or this permit shall on doemcd revalued.
CONSTRUCTION LENDING AGENCY
1 hereby a01. W, them u construction lending agency for the peno.ance of
tI
the work which this peat ts issued (Sec. J09'1, Civ. CI
s 3
'
Ni
Landers Name
,
Lentlera Address
1 certify the, I ham mad Misapplication and slam d a the be. information u
' comci. 1 agree m comply with all city and county aNi.nces and sum laws relating in
Wilding consu action. and hereby authoma repmsema ims of this city he enter upon the
abova-mcndomd property for inspection purposes
(We) agree m nm, indemnify and kap hatmless the City of Cupertino against
j liabilitis,Judgments. toss and expenses which may in any way a cam against said City
in OLICcOt zooming this R
3 APPANrSTANDSWIL THALL NON -POINT
Issued by: Date
SOURCE NS.
Re -roofs
Type of Roof
sielmnm Of Appfien✓Cunmcbr Dam
HAZARDOUS MATFIUAIS DISCLOSURE
Will de applicant or future Wilding o.upanc scam or handle hasallon materia
as defined by the Cupenim Municipal Cade. Chapter 9.13, and the Health and Safety
Code. Scotian 21131(.)?
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or funum Wilding occupant use equipment or device which
until heraNnus car contaminates u dcfmcd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yn u
I have read the hbaulms materials requirements under Chapter6.95 ofWc Califor.
nim HcmIm&SafetyCabo.&.4.25505,253]7 and 25534.1undorsund thatifthe Wilding
dors not currently him a tenant, Wet It Is my responsibility to notify We meupart of the
mgammc recoil hnow W met prior m own ... f.CcnffRmteaf Occupancy.
Signature of Applicant Date
f C` z1- 08
All roof coverings to be Class 'W' or better
' '
Owner or authorized ,germ Dam