07050178 CITY OF CUPERTINO
BUILDING DIVISION PERMITTA TOILZ IF`C}RM`A�ION'
DDRESS: PERMIT NO.
BUILDNA
��495 N DE ANZA BLVD NATIONAL CONSTRUCTION 07050178
OWNER'S NAME: TZ - PERMIT ISSUE DATE
SAND HILL/1200 SAN MATEO AVE 15319 CHATSWORTH ST 05/18/2007
,E_T n SANITARY NO. CONTROL NO.
(818) 221-6057
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
p O LICENSED CONTRACTOR'S DECLARATION Job Description
V P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
:Z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is TEMPORARY POWER POLE
y in full force and fe
r 2 License Class �- C ic.fr
E w Date - Contractor
ARCHITECTS DECLAAAMIT
I understand my plans shall be used as public records
)yU
V.y Licensed Professional
y OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
`COO following reason.(Section 7031.5,Business and Professions Code:Any city or county
<,�, which requires a permit to construct,alter,improve,demolish,or repair any structure
L1 y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 S I.Ft. Floor Area $1400
2 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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 ofNumber Occupancy Type
not more than five hundred dollars(5500). 32 633 11Cff
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is notintendcd oraffemd forsale(Sec.70",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
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.).
❑I,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-
ccnse 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.
❑I am exempt under Sec B&P C for this mason
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 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 Workees Compensation In ce carrier and Policy number arch L/
Carrier: S Policy No:
CERTIFICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foranc hundred dollars(S 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 most
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z `~ CONSTRUCTION LENDING AGENCY
E-r rA I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W A lender's Name
ate
. z Lender's Address
U C-) I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes. `
(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 �t
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
S CE REGULATIO S.
mak" C'7 Re-roofs
Signature of Applicant/Contractor VDate Type of Re of
HAZARDOUS MATERIALS D CLOSURE yp
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 roofs s]Iall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant r 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 comamin is defined by the Bay Area Air Quality Management all new materials for inspection.
District?
C]Yes Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 75534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
rcqu' is which most x met nor w issuance of a certificate of Occupancy. Signature c f Applicant Date
All roof coverings to be Class"B"or better
Owner or authorize gent U Date
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 326 33110 . 00
DATE ISSUED. . . . . . . : 05/ L8/2007
RECEIPT #. . . . . . . . . BSO )0001380
REFERENCE ID # . . . 07050178
SITE ADDRESS 10435 N DE ANZA BLVD
SUBDIVISION . . . . . .
CITY CUP-,RTINO
IMPACT AREA . . . . . . .
OWNER SAND HILL/1200 SAN MATEO AVE L
ADDRESS 30 E 4TH AVENUE
CITY/STATE/ZIP . . . : SAN MATEO, CA 94401
RECEIVED FROM . . . . : EDWARD GREGORY
CONTRACTOR NATIONAL CONSTRUCTION RENTALS LIC # 22537
COMPANY NATIONAL CONSTRUCTION RENTALS
ADDRESS 15319 CHATSWORTH ST
CITY/STATE/ZIP . . . : MIS3ION HILLS, CA 91345
TELEPHONE (813) 221-6057
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 100 .47 0 .00 100 .47 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 100.47 MASTERCARD
---------------
TOTAL RECEIPT 100 .47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
CITY OF CUPERTINO
TEMP POWER
CITY OF
-UPERTINO PERMIT APPLICATION FORM 76
APN# Date: J
lf
Building Address: 1 vJ
Owner's Name: Phone #:
/*J L, 1 5,-, M-1 Jv I_L, C 6-5-0-- Y 65v0
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"4tractor,'Gl �L?.�f G �,�t /S- �yPho�/O/- 2�0- 2 /mac)Z) License#:
Contact: Phone: Cupertino Business License M
Nnr*h Plum Remit Servies Edward Gftgory 9 ZS _. y,7-
Building Permit Info: ---Fe YT PO Ce�
Elect ❑ U 7 Oa G O /0 1
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 BL.siness License BUILDING
a