09030009 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � �' �` � '
PERMIT NO.
BUILDING ADDRESS:
10651 CARVER D.P. CO\4STRUCTION 09030009
PERMIT ISSUE DATE
NER'S NAME:
VA
A CONTROL NO.
PHONE:
(408) 655-9582
BUILDING PERMIT INFO
ARCHTTECI'/ENGINEER: BLDG ELECT PLUMB MECH
0 0 0
u o O LICENSED CONTRACTOR'S DECLARATION Job Description
W C I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
zm in uSeorcean effecDivision3oftheBusinessandProCesstuns�3dmylicense is INSTL TEMP POWER POLE
n=y in full force and effect (oG 1
.=,,1
vn Z License Class Lac,
3—a
8
3 F,a Date Contractor
AItCHrTFcrS DECLA ATION
I understand my plans shall be used as public records
�yU
n Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
,4 0.66 which requires a permit to construct,alter,improve•demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
yt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $800
y 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 w a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 37534049 . 00
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
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.).
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-
ccuse 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 Sea B&P C for this reason
«ner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 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 Workces 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:
Cartier. 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 Icss)
1 certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any mannerp as to to the Workers'Compensation
Laws of California.
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
0 O forthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
Ln
(~—h 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 Q Lendces Name
0Z
Lender's Address
U C) 1 certify that I have read this application and state that the above information is
LL r� correct.l agree to comply with all city and county ordinances and sure laws relating to
Vbuilding construction,and hereby authorize representatives of this city to enter upon the
a &hove-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against \
rF-t liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. 6 Date ' ! /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b j:
SOURCE REGULATIONS. 1
31-3101 Re-roof: 1 —
Signature of Applicant/Contractor Da Type of koof \\
HAZARDOUS MATERIALS DISCLOSURE v
Will the applicant or future building occupant store or handle hazardous material
lefined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
.ide•Section 25532(x)? All roof;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
emit hazardous air contaminan"fined by the Bay Area Air Quality Management all new inaterials for inspection.
District? ;No
0Yes
1 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
does not currently have a tenant th u is my responsibility to notify the occupant of the
requirements hick m be met prior issu ce of a certificate of Occupancy. Signature of Applicant Date
All roof coverings to be Class"{``or better
Owner or authrized agent Date
CITY OF CUPERTINO 09c)3
TEMP POWER
CUPEk ANO PERMIT APPL[CATION FORM
APN # Date:
00
Building Address: 1 a 6�– 1 2 �J i
Owner's Name: M 0 fj K f� Phone #:
Ifo 8
Contractor: Phone #: 4y
Fax #:
Contact: fA0 (\J Phone #:
Contractor License #: 3 2 3 I
Cu ertino Business License #:
Job Description: SNS ZM�� �,a PO 0 r PU t-r
Residential Commercial
Valuation (cost of project) Type of Construction: N/A
i!jo—
Quantity Fee ID Fee Description Fee Group Permit Type
IERT>lK Res. Temp Power>IK E IREAPI4
Amps
IERT<200 Res. Temp Po•Ner<200 E
JAmps
1 ERT2001 K Res. Temp Po ever 200-1 K E
Amps
IEPERMITFE Electric Permit Issuance E
1
I ELCPLNCK Electric Plan check E
1BCBSC Cal Bldg Standards B ALL PERMIT _
Commission Fee TYPES
l 1BSEISMICR Seismic Residential B
ITRAVDOC Travel & Documentation B
Fee
Revised 01/07/09