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09080082 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20184 PACIFICA DR CONTRACTOR:DANCE BUILDERS PERMIT NO:09080082 OWNER'S NAME: FRANK&MARY ROLLER 3939 OCCIDENTAL RD DATE ISSUED:08/10/2009 ( -R'S PHONE: 40S7725221 SANTA ROSA,CA 95401 PHONE NO:(707)546-0802 ❑ LICENSED CONTRACTOR'S DECLARATION /r� .�/ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# 5'0tpQ uF F �� MECH RESIDENTIAL COMMERCIAL Contractor ��`�' Date 0'�©�A� I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEMPORARY POWER POLE (commencing with Section 7000)of Division 3 of the Business&Professions , Code and that my license is in full force and effect. t I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the Sq.Ft Floor Area: Valuation:$350 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:36928018.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon'he above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. I indemnify and keep harmless the City of Cupertino against liabilities,judgments, I costs,and expenses which may accrue against said City in consequence of the / granting of this permit. Additionally,the applicant understands and will comply Issued by: v/ Y� Date: with all non-point souse regulations per the Cupertino Municipal Code,Section 9.18. 1 Signatur ^� Date RE-ROOFS: �— All roofs shall be inspected prior to any roofing material being installed. If a roof is i❑ OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant. Date: 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, 1 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) i 1,as owner of the property,am exclusively contracting with licensed contractors to constrict the project(See.7044,Business&Professions Code), HAZARDOUS MATERIALS DISCLOSURE i I hereby affirm under pegalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain a t_ertiticate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should 1 store or handle hazardous material. I performance of the work for which this permit is issued. Additionally,should 1 use equipment or devices which emit hazardous air I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Section 3700 of the Lahor Code,for the performance of the wei k for which this Health&Safety Code,Sections 25505,25533,and 25534. permit is issued. 1 cerify that in the performance of the work for which this permit is issued,I shall Ow�tgr�or authorize62ti—r= I not employ any person in any manner so as to become subject to the Worker's//�� Dat,:��Q, � Compensation laws of California. If,after making this certificate of exemption,1 become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY R forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued(Sec.3097,Civ C.) APPLICANT CERTIFICATION Lender's Name I certifv that I 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 Lender's Address !to building construction,and hereby authorize representatives of this city to enter Iupon the above mentioner,'property for inspection purposes.(kVc)agree to save ARCHITECT'S DECLARATION in, 'fy and keep harmless the City of Cupertino against liabilities,judgments, ck .gid expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granon-'of this permit.Adaitionally,the applicant understands and will comply with all non-point source regulations per the qupertino Municipal Code,Section Licensed Professional 9.18. jSignawfe_-- ^— _-- _Date CITY OF CUPERTINO TEMP POWER CUPEkTINO PERMIT APPLICATION FORM APN # Date: ?? (a Building Address: 19 y `4r_(F1 CA- br. Owner's Name: Phone #: 1-10(3 -77 z-5 Z ZI Contractor: Phone#: 7,7 S�b-O 6 of� T 4P-C-,2- v�� _�$ C ry✓t1eS Cil t-107 zZF3 -.Ss76 Fax #: '70-7 574 -06 z Contact: Phone #: (7v 7 In 22 - S70 Contractor License #: 50602-1 Cupertino Business License #: n Job Description: Residential Commercial ❑ Valuation (cost of project): , Type of Construction: N/A 81S� Quantity Fee ID Fee Descript.on Fee Group Permit Type IERT>1K Res. Temp Power>1K E 1REAP14 Amps 1 I ERT<200 Res. Temp.Power<200 E Amps 1 ERT2001 K Res. Temp Power 200-I K E Amps IEPERMITFE Electric Permit Issuance E 1 ELCPLNCK Electric Plan Check E 1 1BCBSC Cal Bldg Standards B ALL PERMIT J Commission-Fee TYPES 1BSEISMICR Seismic Residential B 1 TRAVDOC Travel & Documentation B Fee Revised 01/07/09