06010099 CITY OF CUPERTINO �i>� " tea
BUILDING DIVISION pEgMIT CONTRACTOR INFORMXTION
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BUILRINGADDRFSS: FRED CONKLIN PERMITND'06010099
105117) BARNHART CT
OWNER'S NAME FE Mrr LSUEDATE
FRED CONKLIN 10530 BARNHART CT 01/18/2006
NE:
SANITARY NO. CONTROL N0.
ARCHrfECr/PNGINEER:
BURRING PERMrr INFO
' BLDG t]ECT PLUMB HECH
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pop LICENSED CONTRACTORS DECLARATION
Job Description
1 hmcby Num Nat 1 ton Intrad order p,owdmt of CW ptu 9(mmmrxing
m Sauvn riK1U)NDivi.im]of dr Busirtcu.vd Fofuswru COdc..M my Ikctte u
in run fVo, dCffea TEMP POWER POLE
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ARCHITECTLRS DECLARATION
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ARCHITECTS
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OWNER BUILDER DECLARATION 6
> 1 hueby alarm Nal 1 w compo fmm the C.rnmCtor,I io.Li,,for the
O wlrb ng moan.(Satin 7031.5,Btvor ad PmfC.n Code:Any cioY m marry
5 s wbklt tequbs,.permit to onnc,um.,IV.irri e.monolith.ortela,arc v,vaunn $100
priab ioi ivuutcc..L,u nguiru dv applinnl for.11 permio to fika,iyncd vatnrcm
e
no,bCisJ ro jpamurtttothcpmvi ocof bCCmWaeter;Uco=Uw n p� 9 Sq. F[. Floor Area Valuation
e (aaottteaing wido Smion 7")of Di.tion 3 of the Bu,inov aM Pmn9ion,Cale)in
_ ibit k H...rapt thmefram ud ik M,4 for the d1egM evmpuuv Any vblat(on of
Sauon 70]1.5 by aoy.pplk.n,carii primit,ubiom tk.pplkuu in.cowl pcuBy N Amr Occupancy Type
owl nae tWin Bw hundred loi(M3
❑Luowoerk,aM om any uon"o dwghwpouN (S..7W,Be uon,
wBl dothewatt,co,the ammun I,cwts L-;m a in, roc We"to
Bt or
and Pmre„lau caQ:The emtu.emr,Latae�w aero car•wN m.�owner or Required Inspections
po�Y wow bWlm a Imprms,tivco^,and wbo dau,tdo wont hitveJr or NmoLh hI,
won voployce,,prowdM thu,och imPomsm•"•art om irteMM oroRvd tante B,
hove sC,ip bolldinfouclorr etrcn,is it withinone5s.r or irr kfrtheowna-
bu0der wl h.,c Otc buNuo or pmwnt tout k mtl tta bdd err Impmac for purpac or
awrcr of tk pnpcvy.w euduaively coau.cu,wib nmrued cunvacta,In
th
m)=(SIL.7044.Buaittea.rd Pmfu Code:)The Contrv:wr,Li
erne law dou tta a,Pty to to o Npraprnyw buiWa or irm.thceon,.ad,
wbo Contra fa ouch P•^jeeu with.eom,acwt )liatued pConwor•In the Cmvrura
Lio..Ltw.
❑I am',crap,undo sec - // .B&P C far tN,
ru,an
�iwC/ Due
WORKERS COMPENSA.nobl DECLARATION
I IKrMy tuition abler Pculry of perjury onto of tho following Qclantbnc
I lrirt and will munuir it Ccrnfb eof Con,cnl welf-imus for Worloo'.Colo a
tion,to poovl44 for by Section 3700 of the Labor Code,for the perfamuve of the
wart faw tM,pcmit a 1—"
❑1 Nos and will mtiMain Wales;Compeuatlon Inwnrtm,u m*md by Semon
3700 NNe IJkr Code,for the perforrruue of the wont for which thu pvmit u isurd
My Wortrl,Compermum luurt.aria arta Pdicy nookrare:
Comic Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPFNSATIONINSURANCE
(Thu=ficto ttocd not kmnploVI If tk PCMit E for one hurul dM.R(II(o)
or leu)
I CCNry Nat In the pafotma ico of ft rat fa w Cit Ni,permit u Luad I dW I not
cmplvy"'ninninany m.nncr, toh c ectwthe Worlm'CanPcwlV, .
Ion of Califamla.
Applicant L
NOTICE TO APPIJ ANT:If,arseonildrig,.i NI,rsniftue of Exemption. CoyNOWd
bcmnte,ubjaty idWmkar,Coropmuvion porW.it"titho luhm Code,you nuc
.UZ foMwiW comply olid avh prow,iauorthu pctmil,hallkdramd,e.Ned. '
Z'O CONSTRUCTION TENDING AGENCY
I booby irnrm N.t Nca 4.m,u+unlon 101ding aFttcy for tho perfurm.ra of
a > th,work for wbkh N,pemnl,I.Ivned(Sec 3097,Ci,C.)
AIcrQr,Nurse
Ad
a,Z IutQri mu,
U0 1 ci rurY tout 1 woe Ind thu applicuirn W,ate ttit tk abo.e nfo,m.tlm u
lL t.., mtrm l.Lra wcamply wiN dl nryardmunty vNinuae,ard,utelaw,rtivingw
OU bulling cmw Uon,.rd hemby,utborin rtprcenuoics.,of Ni,city to Coto upon the
W tbovc.mcmiattW proRay fm impccuon prapoe,.
(We).gm.to ave,iMmuufy ud kep turmku tho City of CLTCn na.Lv.
y IWilit ,jWLnenu.eou.rk.,oroici which m,y 1..try ny.ax ii,. ,aid Cur
L) In cunegaoce of WC[ranting of NU lcnnit. �/ �
APPLICANT UNDERSTANDS AND WILL COMPLY WI'm ALL NON-POINT Issued by: Date C]
SOURCE REGLL . _ Re-roofs
Sq..NAPA��H �AZVtDOUS MATERIA/IS DISCLOSURE Type of Roof
Will me gpfvnt or fuouc WIldingrc ,,Vtvac a battAc hoounloui no.wutl
U QfinVI by tk Cupenim Municirol CoQ.CbVV 9.12.,rtd tk H Ith.nd SaVy
ode,So-don 35332(a)t All roofs shall be inspected prior to any roofing material being installed.
Yn a
Wil the aMiicutt or fuwrt bonding occup.tu ue equlpmcm Co Qwmu wbkh If a roof is installed without first obtaining an inspection,I agree to remove
It bnnrWtu,dr ennumiunu a,Qnncd by NC B.y Arn Ab Quallty Marugamen all new materials for inspection.
C11
❑Yu
I ha,e read dv ha udous mvc,l,ls rCqubammnu underCNpvrh.93 of tk Caldron,
nu Finoth&Safl,IuvC,Saxon t25503.25533vd Wlh'y tudrmvdIC BNe Indio[
don To eurrtmly bn,c•vtwLL tbv It u my rnpoeuibili,Y w twufY tk atopen of do
rtgairttnen hnowbe=t w:uu.acor.C<ttirm.tnnraatrptal'. Signature of Applicant Date
z l I � � y 1 q`06 All roof coverings to be Class"B"or better
Ovrcr a,utltovN agent Dart
CITY OF CUPERTINO
TEMP POWERCM OF
a �/
AWhCUPERTINO PERMIT APPLICATION FORM
APN # 3 S 3 -7 G Date: p
Building Address:
Q S= �Gr"9`- C`Y
Owner's Name: Phone#: J °
19--re el{ Co� /cl ,n 90�- �-79
Contractor: Phone: License #:
Contact: Phone: Cupertino Business License #:
Building Permit Info: .r po c....«
Elect [4
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Job Description:
Residential [r Commercial ❑
Cost of Project: /-:2 _
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect: Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING