07050287 CITY OF CUPERTINO �T hh
BUILDING DIVISION PERMIT �+ � � �
BUILglJt{Qp�8ES PERMIT NO.
ANTA CLARA AV EMILIO FRANCISCO 07050287
OWNER'S�JNlAME: PERMIT ISSUE DATE
EMILIO FRANCISCO 05/31/2007
NE: SANITARY NO. CONTROL NO.
ABUILDING PERMIT INFO
RCHiTECT/ENGINEEX:
BLDG ELECT PLUMB MECH
(� 0
p p LICENSED CONTRACTOR'S DECLARATION Job Description
W PI hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and Professions Code,and my license is TEMPORARY POWER POLE
I< in full force and effect.
izs License Class Lick NO CONTRACTOR PER BOB S
F Date Contractor
ARCHITECTS DECLARATION
,,-J I understand my plans shall be used as public records
7yU
'u.yLicensed Professional
y c OWNER-BUILDER DECLARATION
> 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
*00 following reason.(Section 70,31.5,Business and Professions Code:Any city or county
$rE which requires a permit to construct,alter,improve,demolish,or repair any structure
1Z- prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
e x that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $400
ot— (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or
.. 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 e�pJ Number Occupancy Type
not more than five hundred dollars($500). 3 2 624 014:'t!Y b
0 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 q p
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.).
WIas owner of the property,am exclusively contracting with licensed contractors to
i
tonantet 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.
0 1 am exempt under Sec B&P C for this reason
WORKER OMPENSATION D�LARATION
I hereby affirm under penalty of perjury one of the following declarations:
Q 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.
0 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 Insurance carrier and Policy number are:
Carrier. 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 manner 2r_tbW c subject Vie Workers'Compensation
Laws of Califg ''Date
Applicant_j `A
NOTICEItMOPLICANT.If,after 4liking 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
1 hereby affirm that there is a construction lending agency for the performance of -
.� the work for which this permit is issued(See.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
U C) I certify that 1 have read this application and state that the above information is
V. correct.I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representatives of this city to enter upon the
a 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
V Z in consequence of the granting of this permit.
►- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by Date
URCE REGULATIONS.
]-o rpt3-•-�c�.2��v h�"��"� Re-roofs
Signature of ApplicalISContractor DateType of Roof
HAZARDOUS MATERIALS DISCLOSURE
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 ;hall be inspected prior to any roofing material being installed.
❑Yes 0 N
Will the applicant or future building occupant use equipment or devices which If a roof i;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?
Cl Yes j No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prier to issuance of certificate of Occupancy. Signature of Applicant Date
�"` _p 79L All roof coverings to be Class"B"or better
Owner or authorized a n1 Date
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: B11: Lot :
APN 32624014 . 00
DATE ISSUED. . . . . . . : 05/31/2007
RECEIPT # . . . . . . . . - : BS000001507
REFERENCE ID # . . . : 07050287
SITE ADDRESS . . . . . : 10130 SANTA CLARA AV
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER EM=:LIO FRANCISCO
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : EM7LIO FRANCISCO
CONTRACTOR LIC # *OWNER*
COMPANY EM=:LIO FRANCISCO
ADDRESS
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY INOUNT 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 visa
---------------
TOTAL RECEIPT 100.47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
OWNER-BUILDEIR VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. All the work autho-ized by this permit
B. — A portion of the work
C. — None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. — A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' cor ipensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
...............................................................................................
I declare under penalty of perjury that the al)ove is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature:
TL4 L
Date: S 3
Job Address: 101 3 V ��'--- � C�Lati a '�, Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
-� CITY OF CUPERTINO
TEMP POWER
CUPEkTINO PERMIT APPLICATION FORM
D70,5JR87
# Date:
APN
014, _ 31 - a
Building Address:
Owner's Name: Phone #:
i o — A C-1 S C.D-Ai fi.
Geee : Phone: License#:
Contact: Phone: Cupertino Business License :
s�-
Building Permit Info: _____v... .._.
Elect &' Le 2
Job Description:
Residential 4 Commercial ❑
Cost of Project:
pp. flo�•�=
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP T,-mporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
f-WEt�TINO
Building Department
JOB ADDRESS: PERMIT# _
lD 1 3 r -4 '-4 070
OWNER'S NAME: } PHONE #
GENERAL CONTRACT R: FAX #
I am not using any subcontractors: c a _ cmc-c:�2c--f
Signature Date
Please check applicable subcontractors and complete 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