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07050205 CITY OF CUPERTINO C.ONT oliukiTIN' BUILDING DIVISION PERMIT j PERMPf NO. BUIL TBD - TO BE DETERMINED 07050205 4p(�"THISHOLM AV PERMIT ISSUE DATE OWNER'S NAME: 05/9.1 /2007 BECKER RICHARD A AND NANCY M SANITARY NO. CONTROL NO, ,NE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: TEMPORARY ])OWER BLDG EO PLUMBMD X O ZLICENSED CONTRACTOR'S DECLARATION Job Description U E• 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 70(10)of Divrs n 3 of the Business and Processions ode,and my license is =ti in full force and effect. Lic 8 License Class s Conitacta t w ARCHITECTS DFCLA N aa 1 understand my plans shall be used as public records wU a w E Licensed PmCessional O< OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License Law for the .00 following reason.(Section 7031.5,Business and professions Code:Any city or county Valuation m which requires a permit to construct.alter,improve,demolish,or repair any structure F[ Floor Area i"rn prior w its issuance,also requires the applicant for such permit to Glc a signed statement' a that h is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 S9 i 0 (commencing with Section 7000)of Division 3 the the Business and Proon.Any vi Code)or Occupancy Type a that he is exempt therefrom and the basis for the alleged exemption.Any violatioof AP11 Number Section 7031.5 by any applicant for a permit subjects the applicant to a civil penaltyOf not more than rive hundred dollars(55(10)• ❑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 ro tion,red or owner however,the building or improvement is sold within one year P builder will have the burden of proving that he did not build or improve for purpose of sale.). am exclusively contracting with licensed contractors to ❑1,as owner of the property. construct the project(Sec.7044•Business and Professions Code:)The Conttacoes Li- reon,Ind. who contracts for such not projects with a conttac or(s)y to an owner of property who pursuant to the roves Contractor's License Law. B&P C for this reason ❑I am exempt under Sec. Date Owner 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 far 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 Codc,for the performance of the work for which this permit is issued. My Wor r Co pensa'on Inst ncc carrier and Policy no tbcr are: Cartier. Policy No.: ERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is Cor otic 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 Z forthwith comply with such provisions or this permit shall be deemed revoked. Z� CONSTRUCTION LENDING AGENCY E t►. 1 hereby affirm that there is a construction lending agency for the performance of the work for which this r Mf is issued(Sec.3097,Civ.C.) W Q Lender's Nd 04 Lender's Ad III V 0 1 cent[y that I have read this application and state that the above infortnalion is cortect.]agree to comply with all city and county ordinances and state laws relating to 0 building construction.and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. >� nWi (We)agree to save,indemnify and keep harmless the City of Cupertino against ^ �� FH„t liabilities,judgments,costs and expenses which y in any way accrue against said City Date 'L V Z in consequence of the granting of this rmit. APPLICA UNDE TAN A WeL OMPLY WITH ALL NON-POINT Issued y: , SOURCE U Ti S. [Re-roofs Signature o Applicant/Con for Date 'I' a of Room HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material d Safety as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health any Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. Cl Yes a If a roof is it stalled without first obtaining an inspection,I agree to remove Will the applicant o future building occupant use equipment or devices Management l new materials for inspection. emit hazardous air contaminants as defined by the y Area Air Quality District? ❑Yes o I have read the hazardros materials requirements under Chapter 6.95 of the Califor- nia HcaIN&Safety C tions 25505,25533 and 25534.1 understand that if the building Date does not cu tly h a ant.In it is my responsibility o notify the occupant of the c hich ust met pri r to issuance of a Certificate of occupancy. Signature Of Applicant rcliulm ?,( All roof coverings to be Class"B"or better Date nrr or authorized agent _ CITY OF CUEERTINO 2 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: lot: APN 32641C80. 00 DATE ISSUED. . . . . . . : 05/21/2007 RECEIPT #. . . . . . . . . : BSOO0001405 REFERENCE ID # . . . : 07050205 SITE ADDRESS . . . . . : 10482 CHISHOLM AV SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER BECKEE. RICHARD A AND NANCY M ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1315 RECEIVED FROM . . . . : FIXATION BUILDERS CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----- ----- ---------- ---------- ---------- BTEMP FLAT RATE 1. 00 62 .10 0. 00 62 .10 0. 00 EPERMITFEE FLAT RATE 1. 00 38.37 0. 00 38.37 0. 00 ----- ----- ---------- ---------- ---------- TOTAL PERMIT 1.00.47 0. 00 100.47 0. 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL an CITY OF CUPERTINO -i TEMP POWER CUPERTINO PERMIT APPLICATION FORM ©7D 5005 APN# 37'0 Lit - Ogo Date: S- Z/-O7 Building Address: `d 1 g Z C�iS4dlwl Owner's Name: Phone#: R ALL.-F N A.vt c �e��Pi1' Contractor: Phone: License#: Fs C VVI t4s Twi- 6sa ( Nl3 Contact: Phone: Cupertino Business License#: Mc( SM, 071 Building Pen-nit Info: Elect 1 e-W&Q• �Ovjev- pole, Job Description: Residential 0 Commercial ❑ Cost of Project: / OOO.co Qty. if Applicable Fee ID Fee Description Fee Group BTEMP Temp)rary Power ELECTRICAL EPERMITFEE Elect. Permit Issuance ELECTRICAL BUSLIC Business License BUILDING