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09030020 777777777 CITY OF CUPERTINO BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 22292 REGNART RD WTA RTTTLDER NER'S NAME: PERMIT ISSUE DATE PHONE: S A CONTROL NO. (650) 948-1077 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 0 0 900 LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing Mwith Section 7000)of Division 3 of the Business and Professions Code,and my license is o rn in full force and effect TEMP PC WER TO PERMAN'T METER LOCATION 522 License C Lle•N n t-C Date U�1 �r Contractor\ W) gg ARCHITECTS DECLARATION oC' 1 understand my plans shall be used as public records �yU oin Licensed Professional y g OWNER-BUILDER DECLARATION I hereby alTirm that 1 am exempt from the Contractors License Law for the in O following reason.(Section 7031.5,Business and Professions Cade:Any city or county .<2 fig which requires a permit to consuuct,alter,improve,demolish,or repair any structure a�14prior to its issuance.also requires the applicant for such permit to file a signed statement < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation xH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $100 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 subjccu the applicant to a civil penalty of APN Number Occupancy Type not more man rive hundred dollars(S500). 36647015 . 00 ❑1,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.). ❑1.as owner of the property,am exclusively contracting with licensed contractors to construct the pmject(Sec.7044.Business and Professions Code:)The Contracoes u. cense Law does not apply to an owner or property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractors L)cense Law. I am exempt under Sec. .B&P C for this mason ner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑1 have and will maintain a Certificate of Consent to self-insure for Workers 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 Workers Compensation Insurance,as required by Section 3700 of the Labor Codc,for the performance of the work for which this permit is issued. My Workers Compensationlnsutance carrier and Policy number are: Carrier:�Wo07 n2E Policy No..\'moa-2ozz. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not lie 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 so as to become subject to the Workers'Compensadon 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 Oforthwith comply with such provisions or this permit shall be deemed revoked. Z o ' CONSTRUCTION LENDING AGENCY (~i►�.+ I hereby affirm that there is a construction lending agency for the performance of fx the work for which this permit is issued(Sec.3097,Civ.C.) ALenders Name z Lenders Address U C) I certify that I have read this application and state that the above information is LL"4 corecL 1 agree to comply with all city and county ordinances and state laws relating to Vbuilding construction,and hereby authorize representatives of this city o enter upon the W above-mentioned property for inspection p s PA (We)agree to save,indemnify d p harmless tQITH Cupertino against to liabilities,judgments,costs and expo ich may in anyagainstsaidCity U Z in consequence of the granting of thisDate APPLICANT UNDERSTANDS AN COMPLYL ON OINT Issued bvSOURCE REGULATIONS. b� —� -- Re-roofs Signature of Applicant/Contractor Dao T of l Zoof HAZARDOUS MA ALS DISCLOSURE YPe Will the applicant or future but tog occupant store or handle hazardous material .fined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety .e.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes Pb Will a roof is installed without first obtaining an inspection,I agree to remove ll the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay,Area Air Quality Management all new r Iaterials for inspection. District? ❑Yes o 1 have re the harardas materials requiremcn under Chapter¢.95 of the Califor- nia Health&Safct Code, ec uons 25505.25533 oral 34.I undcrstan mat if the building \ docs not curentl have tegant,that it is my responsi 7ity o noti the occupant of the requirements wh'h mu Itc met prior.tv.is5!I?1tS�, f Occupancy. Signature:of Applicant Date All roof coverings to be Class"ror better Owner or authotn d agent Date CITY OF CUPERTINO TEMP POWER CUPEkTINO PERMIT APPIJCATION FORM APN # f r - l.� r Date: ��io Building Address: Owner's Name: �� ,� Phone #: Contractor: Phone #: �- � Fax #: "1 4� fl( cQ Contact: Phone #: -64 [ uU esL�4-rJ D (a,- L22 0(,eQ 6 Contractor License #: Cupertino Business License#: Job Description: -tD rv -� 11Po2� paces R,-►A-..YT koQ��'tvh� Residential Commercial El Valuation (cost of project): Type of Construction: N/A Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Power>IK E 1REAP14 Amps IERT<200 Res. Temp Power<200 E Amps 1 ERT2001 K Res. Temp Power 200-1 K E Amps 1 EPERMITFE Electric Perm:t Issuance E I ELCPLNCK Electric Plan Check E 1BCBSC Cal Bldg Standards B ALL PERMIT Commission lee TYPES J 1BSEISMICR Seismic Resic.ential B 1TRAVDOC Travel & Documentation B Fee Revised 01/07/09 S,a Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPE�TINO Building Department JOB ADDRESS: -,7-2,2-41 2- 4E-C,04eT- vim. PERMIT#SOS W7-0 OWNER'S NAME: KceWriEL4 -fA-:�-t?; PHONE # .0 2s3 5-3 t GENERAL CONTRACTOR )Q 3 1 LteV-3 00- FAX # C00 c142) 1 1L Qo I am not using any subcontractors: S:gnature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI14ESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Wp�&AcYL <kjOG7'• 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