05010077 CITY OF CUPERTINO e •.a „ ,„ ' avow e
BUILDING DIVISION PERMIT �CONTRACTOR�INFORMATION ,
BUILDING ADDRESS: AMS 'ELECTRIC PERMRNL05010077
000 90MFqTFAD Rn
NER'S NAME: PERMIT LSSVUE DATE
KAISER FOUNDATION 5673
ONE: SANITARY 2 CONTROL NO.
(925) 225-1267
ARCHr1ECf]ENGINEFR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uO0 LICENSEDCONIRACnder DECLARATION
U 1 hereby affirm Net I am Iieemc0 under provisions of Chapter 9(commencing Job Description
Smti
wit on 7")of Division 3 of tss feu
o Busineand Proiom Che,ode.end my license is
n�a in full fort a
5�a License Chu Lknd cf L .x r(�� `�1 S ELECT UPGRADE (4000 AMP) /2 BACKUP GENERATOR
=_r_e Dam Contractor volt f-1_, ;C X". CONTRACTOR: AMS ELECTRIC
n eJ ARCHITECTS DECLARATION
1 un&.ad my plans shall he used as public records
DyU
3 o G Licensed Professional
` 3 OWNER BUILDER DECLARATION
iy 1 Wreby affirm Nal I am exempt from inn Contracmr's License law for the
00 following mason.(Send..7031.5,Business and Pmfesvum Code:Any cit.or county
m(v which requires a Permit to construct.a@r,improve,demolish,Or repair any sucmrc
Fry poor to is issuance.also nu,ores the applicant for such Permit o File a signed sutemcro
< Nes he is licensed pursuant othe previsions ofOn,ConuwmrsLicenseLaw(Chapter 9 Sq. Ft. Floor Area Valuation
FFG (commencing wit Section]000)of Division J o(CC B ushrox and Profusions Corte)or
i Nat he is exempt terefrum and to basis for Ne alleged exemption.Any violation of $100000
Section 7031.5 by any applicant for a Ford subjects to applicant to a civil penally of APN Number Occupancy Type
not more Nan five hundred dollars(5500). P Y YP
❑I.W owner of the property.or my employees wit wages as ten sole compnution,
will do the work.and to mumu¢is not intended well for W.(See.7614,Busi. _5160903 7 . 30
and Pmfeuiom Code:The Commemfs License law doer Out apply on an owner or Required Inspections
Own
who W iprovi imposes dere prove who docs suchwmk himulredthough We his
own ,.thecm.provided Natwchim I.sold wi artnot intended oroRertdforswwo-
Wil derv,the W iming or den of proving
is sold a didn one year of completion.Nc owe of
Wilder will hose IhC When of provin6 Nar W did not Wild or improve for purpose of
salt.).
❑st as owner of ct See.7 em exclusively ine d contracProfessions
whir licensed consmomract furs U.
ca.La d project(Sec.1.a. Business f and Profusions Cade:)Theves th i mm's Lh
cave law dors not apply loan owner of property who Wilds or improve Corton,and.
whoLo for en pprojectswith u
a conlrmr(s):ieenum d pursuant Ne CanvactoYs /^
License
w
I nse am(Cov, (�
em exempt antler Sec .B k P C for this resson V �a
Date
WORKER'S COMPENSATION DECLARATION
1 beuby MIlrm under pointy of perjury ow of Cc following declinations:
I hove and will maintain a CcrtiGnte of Consent IO ul(-insure Tor Worker's Compere
..tion,as provided for by Section J]W of to labor Code,for to penormance of Cc
work for which this permit is issued.
❑1 have and will maintain Worker's Compehauon Imurul as mquimd by Section
371 of to Labor Code,for to Peoonm ince of to work for which this permit is issued.
My Workers Copmpuau;Qnl sunny carticr and Policy numMr p
Cartier. I �S JNS P.Iiry No.: w B
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
This union need not W completed if tc Permit is forme hundred dollars(SIM)
or less.)
1 ecnify Nat in the perfor nance of Ne work for which this permit is issued,1 shall not
employ any person in any manner w as N become subject to Ne WOrkcn L'ompn.atiOR
Law.of California.Dau
Appel ml
NOTICE TO APPLICANT:IL after making Nis Ccni0cnte of Exemption,you should
become subject m use Workers Compensation provisions of to Labor Code,you most
.,z fortwit comply wit such previsions or tis Permit shall W deemed invoked.
Z O CONSTRUCTION LENDING AGENCY
F'
I thereby (firm tat tort is a construction lending g agency for to Perfurmanee of
C4� ,lurk fur which Nu permit is issued(Sec.3 ,[iv.C.)
Le
C>J Q I<ndcr's Name
Ui Addrss
U haw
UO Conify iLhthis ty and county
and soon out nd soon laws
IS
pUcuildin I agree torn,and wiNColl city and county ordinwcef and sou laws relating to
atiownBcodioned repand herons auNanrzsepmscnuuvcs of tis city to enter upon to
ahovc mentioned property for impaction purpose.
F 6
(We)agree to save,indemnify and keep nay in m the City of Cupertino sold
City 1
(A liebilide,judgmcnu,cosu andePensu which may in any way attme against said City /%J G
Uz into nee oft ting of Ni.permiL Z'
^ APP ICA UNDERSTANDS AND WILL COMPLY WITH A NON-POINT Issued by: Date
SOURCE REG CATIONS.
Re-roofs
Si aHAZARDOUS
ppliaDem
yaHAZARDOUS MATERIALSt sum,or
Type Of ROOF
Will On applicant or(more building Occupant ante Cor handle havaNuund material
u defined by on Cupertino Munici Code,Chapter 9.12,and Ne Hcalt and Safety
7Dwict'
Sccdon 15533(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yc.Will tc a cent or future WI c occ.ant me a ui If a roof is installed without first obtaining an inspection,I a ree to remove
PO B p 4 Pr Qu or devices which gharardnus air conumimnncJ byNoBayArcaAir Quality Management all new materials for inspection.
❑Yes1 have mad to ha NnusmamrialsmquimmenuunderChapter695ofdeCalifon
moa ,w..nLtil .note have a¢nano Net it u my rcapemibility to notily Ic cupansofNc
rmcnuwhi mplxmetpnormiswwanracemnemofacupmcy. Signature of Applicant Date
All roof coverings to be Class"BI'or better
or ser auNorivne agent Dem