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09040143 CITY OF CUPERTINO BUILDING DIVISION PERMIT � ' � ' PERMIT NO. BUILDING ADDRESS: 10552 JOHN WAY L C 1?ERbIIT ISSUE DATE OWNER'S NAME: —sWA CONTROL NO. 415) 585-3884 BUILDING PERMrr INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH a p ZO LICENSED CONTRACTOR'S DECLARATION Job Description to 5 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing i m with Scetion 7 )of Divi 3 of the Business and Professions Code,and license is TEMP P Ow ER POLE y in full Cora an effect v�2 Licensc C Contractor —" Date � HrfECTS DECLARATION od I understand my plan shall be used as public records DaU 3"Wo y Licensed Ptufcssional OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's Liccnsc Law for the in O following reason.(Section 7031.5,Business and Professions Code:Any city or county K Qi which requires a permit to construct,alter,improve,demolish,or repair any structure a"y prior to its issuance,also requires the applicant for such permit to file a signed statement Eq.Ft.Floor Area Valuation Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Y.t= (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or81000 y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number not more than five hundred dollars(5500). 3591800-1 . 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 or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Conuactoes 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.). ❑1,as owner of the property,am exclusively conuacting 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 Contractofs License Law. ❑I am exempt under Sec .B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: J 1 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. ❑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 WorkefCa pensation Insurance carrier and Policy number are: Carrier. r h�1 Policy No.: ERTIFICATE OF EX PnON FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars(S 100) or Icss.) 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'Compensation 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 r 4 CONSTRUCTION LENDING AGENCY C/) 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 QLendees Name 0 Lender's Address U C) I certify that I have read this application and state that the above information is (L H correct.I agree to comply with all city and county ordinances and state laws relating to OU building construction,and hereby authorize representatives of this city to enter upon the W above-m ndoned properly for inspection purposes. LL c)agree to save indemnify and keep harmless the City of Cupertino against Hliabiliti j menta,cos and expenses which may in any way accmc against said City U Z in co of the g ng of this permit Date �� APPLIC NDER ND$AND WILL COMPLY WI LL NON- OINT Issued by, - SOURC R 1�(J- ,y Re-roofs Signature of ApplicanuC"'o tractor T of Roof H OUS MATERIALS DISCLOSURE Type Will the appli=4 future building occupant store or handle hazardous in rial as defined by the Cupe o Municipal Code,Chapter 9.12,and the Health and afcty Cole.Section 25532(x)? All roofs ;hall be inspected prior to any roofing material being installed. C]Yes Ne If a roof i;installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment ordevices which all new m aterials for inspect-ion. At hazardous air contaminants as defined by the Bay Area Air QualityManes-mcnt District? ❑Yes 1 have a hvardous arerials requiremcntt under Chapter 6.95 of the Califor- nia Health&Sy &,= 505,25533 and 75534.1 understand film build'g docs not curren y ha a tenant it is my responsibility to notify the cupant n reyuiremcnts w i, be mel p or to issuance of a Ccrtificate of e 6 Signature of Applicant Date All roof coverings to be Class's.'or better Owner or authori d agent Date CITY OF I�UPERTINO ` TEMP POWER CUPE�TINO PERMIT APPLICATION FORM APN # U 0-7- 0 Date: G� Building Address: Owner's Name: Phone #: Contractor: Phone #: 4 C> �_ :77 l.Jl� C�G'�NST�vL�t6� . ► h1 Fax #: 6;. &z —v1' z Contact: Phone #: -�- ,►tires 1.._.o 41 ' m Contractor License #: t> ir� Cupertino Business License #: Job Description: Residential Commercial Valuation (cost of project): Type of Construction: N/A Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Poi ver>1K E 1REAP14 Amps IERT<200 Res. Temp Power<200 E Amps 1 ERT2001 K Res. Temp Polver 200-1 K E Amps 1 EPERMITFE Electric Permi: Issuance E 1 ELCPLNCK Electric Plan Check E 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICR Seismic Resid-,ntial 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 ;UPEkTINO Buildhijg De artment JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # i — 3-01- GENERAL CONTRACTOR: LK , G'vN 60w + N c_ FAX# o - S2- CjZ r I am not using any subcontractors: Sif nature ate Please check applicable subcontractors and comF lete the following information: kA 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 Ro k Tile Date Owner/Contract Signature