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09020115 CITY OF CUPERTINO G :1A+ T+CT It? MA �I : BUILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 09020115 1017 P PERMIT ISSUE DATE NER'S NAME. A CONTROL NO. PHO BUILDING PERMIT INFO ARCHITECTIENGINEER: B� E� PLUMB MLE_C7H y ed o LICENSED CONTRACTOR'S DECLARATION Job Description VI 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 TEMP POWER POLE 2,4 y in full force and effect 0 z License Class p Contractor F- Date ARCHITECTS DECLARATION tt I understand my plans shall be used as public records Licensed Professional OWNER-BUILDER DECLARATION r 1 hereby affirm that I am exempt from the Contractors License Law for the no following reason.(Section 7031.5,Business and Professions Code:Any city or county a P which requires a permit to Conswct alter.improve,demolish,or repair any structure Valuation tr'w prior to its issuance,also requires Ute applicant for such permit to rile a signed statement Sq.Ft.Floor Area Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 �l x (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the baso for the alleged exemption.Any violation of ApN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of t more than five hundred dollars(5500). 3 2 6 2 2 0 3 r r . 01 ra 0 1,as owner of the property,or my employees with wages as their sole compensation, for sale(Sec.7044.Business Required Inspections will do the work,and the structure is not intended or offered and professions Code:The Conuacar's License Law dors not apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employes,provided that such improvements are not intended r etio the sale. the building or improvement is sold within one year eP builder will have the burden of proving that he did not build or improve for purpose of sale.). 0 1,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 contractor(s)licensed pursuant to the Contractors License Law. ,B&P C for this mason "j 1 am exempt under Sec Dale 2,-7 r WORKER'S C pENSATION DECD RATION I hereby affirm under penalty of perjury one of the following declarations: for we f" u sa I have and will maintain a provided row ded for b Section 3700 of the Laboficate of Consent rC lode, as ethe performancee of for Workees sation,as pro� Y work for which this permit is issued. 0 I have and will maintain Workers Compensation Insurance,as required by Section 3700 of the for the performance f the work My orker Compens o Compensation insurance carrier and Policy numher am:s permit is issued. carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need Trot be completed if the permit is for one hundred donars($100) or less) I cenify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so}t to become subject p the Workers'Compensation Laws of Cali retia.Date — Applicant this certificate of Exemption,you should NOTICE TO APP CA :If,aMr ng become subject to the Worker's Compensation provisions of the Labor Code,you must 2, forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY I hemby 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 Q Lender's Name Z Lenders Address certify that I have read this application and state that the above information is LUL correct 1 agree a comply with all city and county ordinances and state laws relating to O V building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes G7, (We)agree to save,indemnify and keep harmless the City of Cupertino against �7 s liabilities,judgments,costs and expenses which may in any way accrue against said CityAo%dj Date V Z in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SO CEREGU�LJn_ONS.�.�t 27/°�/ Re-roofs Signature of Applicant/Conuaclor Dare T of Roof HAZARDOUS MATERIALS DISCLOSURE Type Will the applicant or future building occupant store or handle hazardous material def ncd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety An,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. 0 Yes ° If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which all new materials for inspection. emit hazardous air contaminants by the Bay Area Air Quality Management District? C]Yes ° I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,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 Date requiremen hick mtm x met prior to issuance of a Certificate of Occupancy. _ Signature of Applicant Z�� All roof coverings to be Class'} or better r� Date Owner or authorized agent Dq OL�100-5 CITY OF CUPERTINO TEMP POWER CUPERTINO PERMIT APPLICATION FORM Date: rAPN # e 1 a �C� 3 /. 01 Building Address: �,-217o .��su�2 vc� e 100 Phone #: Owner's Name: qfo0,a __-41?7 — f e Phone #: Contractor: Fax #: Phone #: Contact, Contractor License #: Cu ertino Business License#: Job Description: Residential Commercial Valuation cost of project): Type of Construction: N/A Va ( p Quantity Fee ID Fee Descri tion Fee Group Permit Type IERT>lK Res. Temp Power>IK E 1REAP14 Amps IERT<200 Res. Temp Pcwer<200 E Amns 1 ERT2001 K Res. Temp Power 200-1 K E Am s IEPERMITFE Electric Permit Issuance E 1 ELCPLNCK Electric Plan Check E 1BCBSC Cal Bldg Standards B ALL PERMIT _ Commission Fee TYPES 1BSEISMICR Seismic Residential B ITRAVDOC Travel & Documentation B Fee Revised 01/07/09 OWNER-BUILD ER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform A. ZA11 the work authorized by this permit B. _ A portion of the w irk 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 _F 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understanc.that I may be an employer(see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. PersorVFirm Address/City Phone Number Type of work to be _performed .....................................................................................................................................................................•............... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse side). Property Owner's Signature: �'�/`'� _� Date: -)-7 l Job Address: ii n ��Yt Permit# Ani changes to the.information provided on this form shall be submitted to the City of Cupertino Build Department. + Community Development 10300 Torre Avenue -bi °' Cupertino CA 95014 Telephone(408)777-3228 aft OF Fax(408)777-3333 CUPEkTINO Building Department JOB ADDRESS: PERMIT # 0170 t2e-,q 54kleg- ,�,, � 'aha Ceo`? C> c OWNER'S AME: i C 04 C- f PHONE # off' --vl-7 --0 a--(- GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and corn. lete the following information: SUBCONTRACTOR BUSTVESS 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