09060102 CITE'OF CUPERTINO
BUILDING DIVISION PERMITS
BUILDING ADDRESS PERMIT NO.
10351 S T \ITAU AVETO CONSURUCTTON
PERMIT ISSUE DATE
OWNER'S NAME:
iAAt#'�t�e 8 9 CONTROL NO.
' rm,✓ n n n
(408) 899-1715
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
u 0 p LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
� y in full force and effect. Q�.�6' TEMP POWER POLE, 10 0AMP
D v�Z Licenac Clan Lr•N ---r----y
3 F p Date Contractor
ARCHiTECCS DECLARATION
I understand my plans shall be used as public records
Dp u
4 C H Licensed professional
rn:5 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
y$V 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 Valuation
E_ that he is licensed pursuant to the provisions oC the Contractor's License Law(Chapter 9 ;>q.Ft.Floor Area
h (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $240
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 to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500)_ 3750801" . 00
0 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 Cafe:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselror 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 Cafe:)The Contractor's U-
cease 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.
0 1 am exempt under Sea B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Conscnt to self-insure for Worker's Compen-
_don,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
0 1 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 Worker's Compe atioran carrier and Policy number are:
Cartier. PolicyNo.:ZL 4 4002AV'7
TIFI ATE O CEMPnON FROM WORKERS'
'COMPENSATION INSURANCE
(rhis 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 so as to become subject to the Workers'Compensation
Laws of Califomia.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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z►r CONSTRUCTION LENDING AGENCY
F~.h►�•� I hereby affirm that there is a construction lending agency for the performance of
�.h^✓ the work for which this permit is issued(Sec.3097,Civ.C.)
W QLender's Name
0. Lender's Address
I certify that 1 have read this application and state that the above information is
LVL� corecL 1 agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
a (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
U Z in consequence of the granting of this permit. Date
�-+ APPLICANT
ro 17 Re-roofs
Signature of Appli ontractor DaA f
Type Of]Roof
HAZARDOUS MATERIALS DISCLOSURE
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(x)? �" All roofs shall be inspected prior to any roofing material being installed.
0Yes MIN.
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
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection.
;trio? /
D yes MN.
1 have read the hazarhttrs materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.I understand that if the building
docs not cu
a cerfficatc of a ancx a Signature of Applicant Date
All roof coverings to be Class'n"or better
Owner or authorized agent tic
CITY OF CUPERTINO 090�ot 0;�
TEMP POWER
CUPEf�TINO PERMIT APPLICATION FORM
APN # Date: 6`f 17 10cl
275D 2O1 `7 . tg
Building Address: 10-351 S' -j A ti i,+c 4V,,—,
Owner's Name: Phone #:
Contractor: k,c kP Phone #:
Contact: Phone #:
Contractor License #: P 06-7— x'67
Cupertino Business License#: :3/0 4
Job Description:
1
Residential VCommercial ❑
Valuation (cost of project): 0 -= Type of Construction: N/A
Quantity Fee ID Fee Description Fee Group Permit Type
I ERT>l K Res. Temp Power>1 K E IREAPI4
Amps
J 1 ERT<200 Res. Temp Power<200 E
Amps
1 ERT2001 K Res. Temp Po ever 200-1 K E
Amps
IEPERMITFE Electric Permit Issuance E
l
1 ELCPLNCK Electric Plan (:heck E
J 1BCBSC Cal Bldg Staniards B ALL PERMIT _
Commission Fee TYPES
1BSEISMICR Seismic Residential B
ITRAVDOC Travel & Doc imentation B
Fee
Revised 01/07/09
Community Development
10300 Torre Avenue
-' Cupertino CA 95014
Telephone(408)777-3228
ClT1f OF Fax(408)777-3333
r.UPEkTINO
Building Department
JOB ADDRESS: 10 Sl PERMIT #
00401 0
2�
OWNER'S NAME:
—
I am not using any subcontractors:_- f
5i gnature D to
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSI14ESS 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