06020085 CITY OF CUPERTINO z � '�
BUILDING DIVISION PERMIT eCONTRACTUR�INFOR�MATI6
BUILDING ADDRESS: PERMIT NO.06020085 6020085
OWNER'S NAME: PERMITISSUEDATE
21
NE: SANITARY NO, CONTROL NO.
ARCH=IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sop LICENSED CONTRACTOR'S DECLARATION
4 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
n� with Such.7") Division 3thc Business andofes ins oQC,andrn vis
u full roue oradclfect. (J CLf GLl
,n Llcon rriClas. Lie.g 2 TEMP POWER POLES
t
Data comuar CONTRACTOR: SBI
ARCHITECTS AR TIO
< 1 undersand my plansshall he used as public records
a o t; Licmad Pmresdonal
ugh OWNER-BUILDER DECLARATION
0 g I hereby maxo aRrm that I am exempt(nsm Ute Convacmes License Lew for IW
i.p O following reason. ami on 7031.3,Busincou and Professions Cade:Any city or county
S$ which requires
a permit to cormauct.slur,improve,demolish,or repair any strucmm
- �,+
prior it)its issuance,also requires the applicant(orsuch Permit to Ole a signed sutement
�
< Ion he is licensed pursuant to the pmvismas of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuau 600
tin
(commencing with Section 7")of Division 3 of the Business and Professions Code)or
tin Nu he is exempt therefrom and Ne bah far Ne alleged exemption.Any vulmlon of
Section 7031.5 by any applicant fm a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
an,matt than Bve hundred dollars(M).
32602070 . 00
❑I.ss owner of the property,a my wplaycet with wages u their sole compensation,
will do 044 work and Ne summon,is not intended or offered has mat(Sec.7044,Business Required Inspections
and Professions Code:The Cervantes License law don not apply man owner of tl P
properly who build,a improves thereon.and who do m mch.,it himself or through his
own employees,provided tat uch Improvements are notlnarded mortared for ala If. _
however,the building or improvement B old within sort you of completion,Ne owner.
builder will haw the burden of proving that he did not Wild or Improve for purpose of
.10J
❑1.as owner of the property,am exclusively contracting wit Iianud contractors to
consumer the pmjat(Sec.70".Business and Prefesdons Cotle:)The Contrseues U.
teat Law data not apply to an owmr of propeny who Wilds or improve thereon,and
who contracts for such pmjecu,with acomramm(U licensed pursuant to the Contractors
License Law. '
❑[am exempt under Ste. .9 k P C for thiswan
Owner Data
WORKER'S COMPENSATION DECLARATION
1 Wreby grim under penalty of perjury one of the following declarations:
I have and will maintain a CenlOnmofCanscnt Mself-insure far Worker's Camper-
don,as provided fm by Section 3700 of the Labor Cade,for the performance of the
wmk for which this permit is Issued.
❑1 haw and will mainum Worker's Compensation formation,as required by Section
3700 of the labor Code.fm the performanceof the wart fm which this permit is armed.'
My Wo L
s Compensation Instance coria and Policy
Cani. I Polity No.:19-/�v-,/-�_�a-� 0w
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not ho complead irthe permit is(momhundn,E dollar(Sim)
or less)
1 certify Nat in the performance of the work for which this permit is issued,I shall not
employ any person in my meaner an as to became subject to the Worked Compensation
Laws of California-Dau
Applicant
NOTICE TO APPLICANT:If,afar making then Coniriau of Exemption,you should
become subject In sae Wooer's Compensation provisions of the Laura Code,you most
.JO roMwith amply with such provi.m.or this permit shN W decreed revoked.
LZy y CONSfRUCHON LENDING AGENCY
[r IWmby M.that thea is a construction lending agency for Ne rmfrmanceof
�i the work for which this Permit is issued(Sec.3097.Civ.C.)
Q lender's Name
=z Lender's Addw
U0 I cenify Met I have read this application and sate that tit show information is '
D.F contact.1 agree an comply with all city and county ordinances and sole laws relating in '
0 U Wilding construction.and hereby avthorine remeamu iws or this city to cnar upon the
{21 above-mentioned property for inspection purposes.
LL (We)agree In saw,indemnify and keep harmless the City of Cupertino against
r.v y liabilities.Judgments,am and expenses which may in any way acme against aid City
f)7 in consequence of the granting or this permit. — �f
A APP C//�tNE UNDERST11NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SS nsf* App T#(!.x
X} i ) Z"y3—n(p Re-roofs
Ignst of Applran enamor Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the CupertmfMuni Wilding occurred Chapter
9.1m aaedle Health and
a OCBmtl by the Cupertino Municipal Code.Chapty 9.12.and ted Health arM Safety '
Code,Scene"25332(.)7 AAll roofs shall be inspected prior to any roofing material being installed.
❑Ya K''in
Will the applicant or rmme building oecupam sew equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hovardnus air contaminants u MAned by Ne Bay Arca Air Quality Management all new materials for inspection.
strict?
❑Yes O(Nu
1 have read the he amus marmials requirements under Chamer 6.95 of the Cali for-
.i.Hesl SafetyCok.SecU=25505,25533 and25534.I uradcrsmrm toss ifthe Wilding
does unity have• Nat u my responsbdity ro andfy,tie occupant or see
mqy m�whie Ipn aiaua.aofacadfica aupaey. Signature of Applicant Date
i 3Dau
ramhariyctl agent DAll roof coverings to be Class "B"or better
Owner
�k Community Development
10300 Torre Avenue
if j ✓' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
#UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
220 ZO /ew .. Q do /Le),D '
OWNER'S NAME: A4 5-1/iip;!:- P- PHONE #,,} O 2"L- ZZO
GENERAL CO CTOR: Z h FAX# - Z - /
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical 1 0
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 A - ,
Owner ontractor Signature Date
alt� CITY OF CUPERTINO
TEMPPOWER �7�'
ICUPQfINO PERMIT APPLICATION FORM
APN# _ m ` O 7 O Date: _ 3
Building Address: V T
2'L A
O 2-0 Nt�mzr end /`�( C✓ e��i�-t c7
Owner's Name: Phone#:
� /�O�Gr✓ t 3117 - ZZ- 22 '
Contractor: Phone: License #:
l (3GL/ lO�f / - �-Z
Contac : Phone: Cupertino Business License#:
as /V L4 t� '73/-z/z- 0
Building Permit Info:
Elect ❑ ?j -h(/Y1 V�it� 5 �� CAMPS
Job Description:
Residential Commercial ❑
Cost ofProjecbr 1 0 S
W b0
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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