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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: ELECTRIC USA PERMIT NO.06010093
18741 NEWSOM AVE
OWNER'S NAME: PERMIT ISSUE DATE
JOSEPH DENHAM 480 ALDO AVE 01/25/2006
PHONE: SANITARY NO. CONTROL NO.
(408) 370-3682
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
UOC LICENSED CONTRACTOR'S DECLARATION
U l= I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
<a with Section 7000)of Division 3 of the Business and Professions Code,and my license is
My imm�foreeandeffea. RELOCATE WASHER/DRYER, INCLUDING
�z,iouDate Contractor Lica UNDERGR. UTILITYT WATER & SEWER, WATER . HEATER
p Datc Contractor
ARCHITECTS DECLARATION CONTRACTOR: ELECTRIC USA (#0100003851)
a
U 1 understand my plans shall he used as public records
4O y Licensed Professional
n w OWNER-BUILDER DECLARATION
a Z 1 hereby affirm that I am exempt from the Contractor's License Law for the
%❑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
Z y, prior to its issuance,also requires the applicant for such permit to Glc a signed statement
E_< that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft..Floor Area Valuation
X t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
$4000
i 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 penally of APN Number Occupancy Type
not more than five hundred dollars($500). P Y YP
❑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
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
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.).
as owner of the property,am exclusively contracting with licensed contractors to
onsttuct 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 Contractor's
License Law.
❑I am exempt underec./ ,B&P C.for this reason
Owner � l® l��f�`, Date �V
WORK,R'S OMPENSATIOta ECLARATION .
I hereby affirm and/pr penalty of perjury one of the following declarations:
❑1 have and will maiLta1ih a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided foiY/'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 Worker's Compensation insurance carrier and Policy number ate:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he 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,1 shall not
employ any person in any manner so as to be o c sub'ecl tg the Workers'Compensation
Laws of California.Date G•
Applicant 1 , !i/trt'
NOTICE TOA L A :If,after maki(tg this Certificate of Exemption,you should
become subjec the Worker's Compensation provisions of the Labor Code,you must
.J Z forthwith cnm y with such provisions or this permit shall be deemed revoked. -
'� V) CONSTRUCTION LENDING AGENCY
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[-� 1 hereby affirm that there is a construction lending agency for the performance of
:4 the work fur which this permit is issued(Sec.3097,Civ.C.)
a0 Lender's Name
2 Lender's Address
U Q 1 certify that 1 have read this application and state that the above information is
"F correct.I agree to comply with all city and county ordinances and state laws relating to
Q U building Conswction,and hereby authorize representatives of this city to enter upon the
W ahove-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
►�-i liabilities,judgments,costs and expenses which may in any way accrue against said City /
U Z in consequence of the granting of this permit /J_��'
"+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ((
SOURCE REGULATIONS.
7 4--fl,
Re-roofs
Signature ofAVp icant/Conlractor Dile
HAZARDOUS MATERIALS DISCLOSURE. Type of Roof
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, es 25532(a)?
F1 YNe All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or f(rc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for Inspection.
District? 1
❑Yes AINo
I have mad the hazardou''sCs materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notily the occupant of the
requirements whit mu4 be met prior to issuance of a Certificate of eopane. Signature of Applicant Date
. I LPe�
Owner or aulhociAll roof coverings to be Class "B" or better
' d agent
:= ITY" OF CLJPERTIIOT®dIV .
C"of PEIT APPLICATION F#AM
CUPEf.T1NO �-us
APN# - Date:
37S- X13 0� d a��� c
Building Address: Mailing Address (if different from building address):
Owner's Name: Phone#:
J� �h�� S✓ ZKOf- C73
Contractor: License#: 7
Contact: Phone: Cu ertino Busines License#: � �
/' , -Zai-i 13y� : P
�.� Fax: -r t�'�1 �G c/ e 0 4� Sv v 1
Build&j Permit Info: Q.L�'+C t 6V l
td,�1n-C�oit—TLA w j�Y s -c r���.✓
Bldg El Elect Plumb I� Mech El
Job Description: , n I.A.2 5T44LL- Co�X4-4 L�x �{v TA-
Residential 006 AeJ- e'y -�-Commercial ❑
Sq.Ft. Floor Area: qFt.:
Cost of Project: - Occupancy Group:
Type of Construction: 1U Please check this box if the project is a
second-story addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1:75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax-Resi/Mobile BUILDING
BELEC 1000 Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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