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09050024 FOWNERUS OF CUPERTINO � IC?RTTif3�S: LDING DIVISION PERMIT pERM1TNo. ADDRESS: 885 MCCLELLAN RD BASEBUIL:� CON DAZE NAME: S R CONTROL NO. (4 0 8) 316-1615 BUILDING PERMIT INFO MECH ARCHITECr/ENGINEER: BCL E�LECT PLC O Z O p LICENSED CONTRACTOR'S DECLARATION Job Description UI hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 70(10)of DivisioAO the Business and Pr tans Code,and my license is TEMP POTA ER POLE Zc wo in full force and effect. 9Sd� v�2 License Class Contractor h Dam X CH1TECPSDECLARATION I understand my plans shall be used as public records D d r o H Licensed Professional OWNER-BUILDER DECLARATION 1 hereby atTirm 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 which requires a permit to construct,alter,improve,demolish,or repair any structure Valuation y"ria 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 a' 450 Y (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or W�� 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(M). 37514008 - 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 Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or through his awn employees,provided that such improvements arc no intended or offered for sale I[, 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.). ❑f,as owner o[the property.am exclusively contracting with licensed contractors to u. construct the project(Sec.7044,Business and Professionsho builds' proves thereoncontr ,cense Law does not apply to an owner of property who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. B&P C for this reason ❑I am exempt under Sec OwnerDate- WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 'have and will maintain a Certificate Of Consent to self"nsum for Worker's Compcn- m,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 permits issued. My WorkL�r_s Compee�nsation Insuranceccarryer and`poc n lie�•9 Cartier 7I-D,ke l�icy'Nn.. C CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ('chis 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,)shall not employ any person in any mauncr so as to become subject to the Workers'Compensation Laws of California.Date ApplicantP au should NOTICE TO APPLICANT:If,after making this Certificate of Excm tion,y become subject to the Worker's Compensation provisions of the labor Codc,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. Z� CONSTRUCTION LENDING AGENCY (~r CA 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 QLenders Name 04 L.cndees Address r7 z 1 certify that I have read this application and state that titc about information is LUL� torten.I agree to comply with all city and county ordinances and state laws relating to 0U building construction,and hereby authorim representatives of this city to enter upon the above-mentioned property for inspection purposes W (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may in any way accrue against said City Date U Z in consequence of the granting of this permit. r-+ APPLIC NT UNDERSTANDS AND WILL OMPLY WITH ALL NON-POINT Issued b3: SOUR Ecu ) 6' Re-roofs Signet licant/ContracWr °"n T of hoof HAZARDOUS MATERIALS DISCLOSURE y) Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes 9\11 I agree to remove If a roof is installed without first obtaining an inspection, Will the applicant or future building occupant use equipment or devices which all new(materials for inspection. it hazardous air contaminants as defined by the Bay Area Air Quality Management Litt? ❑Yes ❑No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility m notify the occupant or the Signatur�of Applicant Date require ms which must be met prior to issuance of a Certificate f Occu�� r `r (/� [ All roof coverings to be Class'V' , or better Date 0 . ')C 0�5 von �f CITY OF CUPERTINO aITYOFTEMP POWER CUPTINO PERMIT APPLICATION FORM APN # Date:2-T51 q0(4, 06 , q Building Address: 2,-V�6 2 p a C C 11 U�� C f Ctk� Owner's Name: Q�l Phone #: Contractor: P, v,��vZ�,c-E Phone L{-© Fax #: Contact: /, 2 CC �__ 2 Phone #: Contractor License #: Cupertino Business License#: Job Description: (f� Residential Commercial ❑ Valuation (cost of project): - Type of Constructio Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Power>1K E IREAPI4 Amps / IERT<200 Res. Temp Pourer<200 E Amps 1 ERT2001 K Res. Temp Power 200-1 K E Amps 1 EPERMITFE Electric Permit Issuance E IELCPLNCK Electric Plan Check E 1BCBSC Cal Bldg Stanc.ards B ALL PERMIT _ Commission B-le TYPES / 1BSEISMICR 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 rUPERTINO Buildiin De artment JOB ADDRESS: Ct t \�U PERMIT # Oct 0�5 0 OWNER'S NAME:\,-k ? -k\, Gam--' E PHONE # - 3 i t b GENERAL CONTRACTOR: 1:3 �lv ( bv)(-' C FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 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 Rock Tile Owner/Contractor Signature Date