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BUILDING DIVISION PERMIT
t .L lit"OTORINFO
BUILDING ADDRESS:
C iY C VALLEY CONST.
PERMIT Nb4060239
2!1490 VAI AV
OWNER'S NAME:
PERMIT MUE DATE
VIVEN SALGAR
2405, KLEIN RD
nr/2q./2on4
ONE:
SANITARY NO. CONTROL N0,
(408)238-1244
ARCHI- ECfyENGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMBMECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
.-
lob Description
1 hereby affirm that 1 am licensed ugdor yaVon - of Chapter 9 (commencing
with Section 7}0110) of Division 3 of lb° Businta ' Phsaushns Code,and my licence is
in full f, W. dcIT ✓"
TEMP POWER POLE
Liceax Lm g
Cmtr
ARCHT"i D ON
1 undersand my pias shall he used u public acofds
Licensed Profcaional
OWNER -BUILDER DECLARATION
I hereby aRnn that 1 am uempt from the Canuutner License Law for the
following reason. (Section 103 1.5, Business and Professions Cade: Any city or county
which requima a Permit to construct. alcor. Improve, demolish, or repair any slmctum
prior e, its isxlnm, elm mquires the applicant for such permit m file a signed summem
thence isliecnsed pursuant to the provisions ofNc Contractor's License Law(Chapmr9
Sq. Ft. Floor Area
Valuation
(commencing with Section 9000) of Division 3 of the Business and Prafasions Code) or
Nat he is eaempc Nene mm and dm basis for the alleged exmpdon. Any violedon of
e30 0
Occupancy e
P Y EYP
Section ]031.5 by any applicant for a Permit subjects Ne applicant in a civil Penalty of
no, mom man five hundred delta. ($503).
❑ L propucy, or wire meati or theinme w0om
RegUII'ed Inspections
is of Immo.
044, B
willo h..O ...d at ]O a4, Business
ill do thcwon% ands: Comore nors
Liendofawricesserad
PmWhoW Cade: The Contnamr'a License Law dam no, apply ll an owner ser
he apply.
property who h, Idsvi1mpmvuhereon,andwho docswchworkhimaelfser through his
far alelL
hwneer,
u, ping dedori
at himprosaid ear
-
th, improvementwit in... ofdormfemd
huilder, thebuildingadenOfPmennisastwithinoneildofmprovefrtheowner-
builder will have he burden of proving mal he did no, build or improve far purpose of
ale.).
❑ h as Owner of um property. am exclnaivaly contracting with licensed cenaaeo. to
/
�/
construct the project (Sec. ]OLt, Business and Professions Cade:) The Contracmis Li.
came Law does not apply in an owner of property who builds or improm tllemes, and
D�
who contracts for such projeem with a caatranor(s) licensed pumum to he Crammer
License Law.
❑ 1 ao exempt under Sec. B As P C for this moon
Owner Dale
WORKER'S COMPENSATION DECLARATION
lans:
I hereby alB,undo, penalty or perjury moo of tho following duntio
m
I hero pad will ..Ionia a CcrtiBcex of Christmas to self-lesum for WOrlmr'sCOmpea-
a Ion, an provided for by Section 37W or the Labor Code, for the performance of the
work for which this permit is iauN.
❑ I have and will maintain Workch Compensation Insurance, as required by Section
3700 of tim Labor Code. far the pertarman t, of the work forwhich this permit is Issued.
My WOrkae.Com nadon Nsunna caniu and Policy number am:
UX M ai pall ee%Y 6n
�
CERTI •IC ATE OF EXEMP170 MWORKERS'
COMPENSATION IN ANCE
OTlssectim need not be completed if tie parmilisrarono hundred dollars (11110i
or Ica.)
I certify that in the peffmaronee of the .,it for which oris formic as issued, l shall our
'
employ any persan in any manncrso an in become subject to the Werke.' COmPensali al
Laws Of California. Dam
Applicant
NOTICE TO APPLICANT: IL after making that Certificate of Exemption, you should
become subject to the Worker'& Compensation pmvisiom of the Labor Code, you mum
forthwith comply with such provisions or his permit shall W deemed mokcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm mat Nem is a construction lending agency for the performance of
one work for which Nu permit Is issued (Su. 3099, Ci, C.1
LandeYs theme
Lender's Address
1 ttnify ha, 1 have read this application and sum mm Ne above information is
'
cement. I aim m comply with all city and county ordinumu and scale Iowa fishing to
building construction, and hereby authorize represenulives Of this city m enter upon me
ahova-mentioned property for inspection purposes.
(We) agree m ave, indemnify and knee harmless the City ser Cupertino ramose
liabilidu,judgmenu,cosu end upcau which may in ay wy accrue against xid City
in consequence of to grmting of this Permit.
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
2g 264
Re -roofs
Type of Roof
_
,anal p'caatfConHAZARDam
OUS MATERIALS DISCLOSURE
Will dtc applicant of ruwre buildin accupaumrc or handle hanNam material
a dented by the Cupertino Muniei 0dc, Chapter 9.13, and the Health and Safety
con. Seen.. 2553200?
All roofs shall be inspected to any roofing material being installed.
0Yes No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will ,he applicant or future building occupant use equipment or devices which
out humdrum air conetinanuadefincd by ay Area Air Quality Management
all new materials for inspection.
District?
Yes
Ihavecoal nts253 under Chapterof the
l�
nicer Cose. Srdnuam 5305. n533 and untera&95men
Wilding
vhat
w
A � ��
nothASallyyhowa recent,tunquimndhuifthebuilding
Jas nal cuncn0y bout a ¢nano Nat it u my responsibility m n til'y she accupat of Nc
it b33Amorems odic
l/\1
�
Imre°"nC.,whkhm�0"P"°rmi"uan`e °raraf/
Si at re of Applicant Da
All roof coverings to be Class "B" or atter
agrnerizaa agem�� ,e
CITY OF
�UPEI�TINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
__-L__ ___/.
I am not using any subcontractors: �ryt Q� Q
Signature Dto
Please check aDDlicable subcontractors and rmmnlete the follnwino infnrmatinn-
• 46
r/Con tractor Signature Y
w Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
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
• 46
r/Con tractor Signature Y
w Date
Sim
CITY OF
UPERTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
D (�ff(,,�37
APN # 3 / Z r--
J
D 2-Z_
Date:
Building Address: 21
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
Owner's Name:
Phone #:
I
Cb
-A,
Contractor:
Phone:
License #:
e.>s L6;
Wi a 2 3-2 12
Contact:
Phone: 6-110-0,7z
Cupertino Business License #:
s C0,
BuildinyPermit Info:
Elect LAYz
Job Description:
�
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Ct a i3 C,—
Residential
Commercial ❑
Cost of Project:
AQty.}
Apvvuc" Fee ID
Fee Descrintion
Fee Grout)
BTEMP
Temporary Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
7
,a-73. 02
•