09040087 CITY OF CUPERTINO � J� Xt
BUILDING DIVISION PERAUT
PERMIT NO.
BUILDING ADDRESS:
10635 CULBERTSON DR NATIONA:j CONST
]?ERMTI'ISSUE DATE
WNER'S NAME: RENTALS
PTTJa. S A CONTROL NO.
PHONE:
(818) 22L-6057 BUILDING PERMIT INFO
ARCHI7ECTIENGINEER: BLDG ELECT PLUMB METH
0
Z p C LICENSED CONTRACTOR'S DECLARATION Job Description
V 1 hereby aflirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3ofthe Business and Professions Code,and mylicense is INSTALL TEMP POWER POLE
n in full force and effect
v�Z License Class LM•R
Date Contractor
t"U4 ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
�yU
Loy Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
O O following reason.(Section 7031.5,Business and Professions Code:Any city or county
y m alter,improve,demolish,or repair any structurewhich requires a permit to Conswct Valuation
prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area
"?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $364
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis 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
not more than five hundred dollars(5500). 37536028 - 00
❑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 oroffered for ask(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law dots 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
psala.j.
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
rty who builds or improves
whocontrace Law does
for such pnot ly to an owner of rojects with a contractor(s)roracPteor(s)I tensed pursuant to
the Contractors
License Law. B&P C for this mason
❑1 am exempt er,,S,,eectt Q
wner /u� 9 Date ��( ��/
WORKER'S COM ENSATION 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.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers 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 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 sp•um nlgsubject to the Workers'Compensation
Laws of California.
Applicant _+
NOTICE TO APPLISANT:If,after making thisCertificate of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you mus
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z 2 CONSTRUCTION LENDING AGENCY
r 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
az Lenders Address
V 0 1 certify that 1 have read this application and state that the above information is
correct 1 agree to comply with all city and county ordinances and state laws relating to
0Vbuilding construction,and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
>4 nWi (We)agree to save,indemnify and keep harmless the City of Cupertino against
,.ty t) liabilities,judgments,costs and expenses which may in any way acme against said City G j dj
V Z in consequence of the granting of this permit. Date
t-- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued t y:
SOURCOTWLATIONS.
Oetl 17 107 Re-roof 3 —
Sig v plicam/Contractor Dare T Of Roof
HAZARDOUS MATERIALS DISCLOSURE Type a f
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mum i al Code.Chapter 9.12,and the Health and Safety
'ode,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C]Yes a If a roo r 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 contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes R(Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,75533 and 25534.1 undersand that if the building
does not currently have a tenant that it is my responsibility to notify the occupant of the Date
requiremc hich must be mete"or to issuance of a Ccnificar of Occupancy Signature of Applicant
4/14 I O, All roof coverings to be Class'}`'or better
Date
Owner or authorized agent
CITY OF CXPERTINO
TEMP POWER
CUPEi�TINO PERMIT APPLICATION FORM NO
APN # Date:
C o D 2�;(Do7
Building Address:
i d 6 s.S- &utg �7Sa� CvQ TirvO, 9rQ 1
Owner's Name: Phone #:��
Contractor: 2�1 G rs Phone #:
.
Fax #:
Contact: Phone #:
Contractor License #: ' R7 1 6 0
Cupertino Business License #:
Job Description: (N ETACC
Residential 1z Commercial
Valuation (cost of project): 56 q Type of Construction: N/A
Quantity Fee ID Fee Description Fee Group Permit Type
IERT>1K Res. Temp Pcwer>1K E IREAPI4
Amps
f I ERT<200 Res. Temp Pcwer<200 E
/ Am s
1 ERT2001 K Res. Temp Pcwer 200-I K E
Amps
/ IEPERMITFE Electric Permit Issuance E
1 ELCPLNCK Electric Plan Check E
IBCBSC Cal Bldg Standards B ALL PERMIT _
Commission Fee TYPES
i IBSEISMICR Seismic Residential B
1TRAVDOC Travel & Documentation B
/ Fee
Revised 01/07/09
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Buildin De artment
JOB ADDRESS: PERMIT #
rahwc ULPCVYa,� .D k,
7 1 2
04
OWNER'S NAME: PHONE # 4 — 6
GENERAL CONTRACTOR: Ow,-A gult-DC-K FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and corn. lete the following information:
SUBCONTRACTOR BUSI:DESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical N 7►at,iAL_ C N;TR uCT(o ��-
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
4/i- /o 3
Date
Owner ontractor Signature