05050077 CITY OF CUPERTINO �-sgv .zwa3•k
t BUILDING DIVISION PERMIT �sCONTRACTOR+INFORMATION
l'd BUILDING ADDRESS: PERMIT NO.
;
K & M DEVELOPMENT INC 05050077
"171 COLUMPUR ANT
OW NER'S NAME: PERMIT MUE DATE
ONE: SANITARY C OL NO.
AR CHITECIYENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
Lap LICENSED CONTRACTOR'S DECLARATION Ib Description
1 hunch,affirm that 1 sm licensed under provision Of:SCO or Chapter 9(commencing - p B
with Sectional of Diviaion3ofNC Buarcs.arW ProfcsdunaC arMmyliccnse is ��Y V��p®
s in full force and effa Iffggf���aL-''
L;cenYaS%j3�Lic.ns TEMP POWER
Date Cunt pts •✓>
q�q ARCHITECTS DECLARATIO
3i 2 I undcrwnJ my plans shell he used u Public ncnrds
—5�/6 2005
G Liecoscd Professional _
QG OWNER-BUILDER DECLARATION
4 i F I heathy affirm Nal I am exempt from Ne Comncmr's License Law for the
0 o following mason.(Season 7031.3.Business and Professions Cade:Any city or countyIL ft"124 �;200
x$ which requires a Permit to convect,a1ur,improve,demolish,or repair any structunc
yzi prior in its issuance,also Wquins the applicant for such permit to rile a signed statement
i<
Out M is ficansed pursuant to one provisions of the Contractor's License Law(Chapter 9 Sq. FL Floor Area a uati(n
xtz (commencing with Sation 7DN))of Division 3 of the Business and Profusions Code)or
;_ that he is exempt Uumfmm and the hazes for dW alleged exemption.Any violation of
Section 2031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 #`e100 Occupancy Type
not mon than five hundred dollars(5500).
❑1,u.wner of the pnpcny,or my cmploycu with wagsuNeir ole campenution,
will do the work,and the structure u not intended or.lTenL tarsale(Sea 201x,Ban.
and Profession Code:The contractors License law does not apply as an owner of Required Inspections
property who builds or imprams themon,and who doessuch work himself orlbrough his
own employees,provided Nat such improvements tae not intended or olfered for sale.If.
Wwevcn Ne building Or improvcmcm is sold within one yes Of completion.Ne owner
builder will ham the burden of proving Nat he did not build or improve for purpose of
vie.).
❑1,as owner of the propcny.am exclusively contracting with licensed connectors to
construct on,projcu(Sac.2014.Business and Professions Code:)The Conlncmfs Li.
cense law docs not apply u an owner of propcny who builds or improves Orman.and,
who contracts for such projects with a dour aa0r(s)licensed pursuant o Ne Carnation's
License law.
❑1 am exempt under Sec. ,B k P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury an of the following decluatimu:
1 ham and will maintain aCertiGe.0 of Consent to self-insum for Walker's Compere
1C33737"'W
mi.n provided for by Section 3200 of use labor Code.far Ne performance of Nc
rk for which this permit is issued.
1 have and will maintain Workefs Compensation Inurma,u required by Section
of the labor code,for the perfmaranee of the work for which Nis permit is issued.
y Workkeerr'sCiCompensation Insurance carrier and Policy number amnnot: G�O"�'J s�liry No.:
CERTIFIUTE OE�PnON FROM WORKERS'
COMPENSATION INSURANCE
(This sachou need not Wcomplated lithe Irrmit is for one hundred dollars(51IX))
kiss.)
1 minify Na in the performance of the work for which this Permit is issued.I shall not
employ any parson to any manner m as to become subjecOo the Workers Compensation
laws of Calif imia.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenifcam of Exemption,you should
become suhjua to N.Worker's Compensation provisions of the Labor Code,you must
.,O FmOwith comply with rush Provision or this permit shall W deemed hamoad.
z'� CONSTRUCTION LENDING AGENCY
[-� I hereby aRrm Out Nen is a mntnnion lending agency,far um of....or
lY the work fur which this permit is Wood(Sec.3141,Ci,C.)
W Q Lender's Name
=,z Lender's Address
V O I cenify Nn 1 ham read this application and sum Nat the above information Is
0 t" correct.1 agree m comely with all city and countyrnmumsaes and stain laws musing m
O V altoveng hereby nsenutivu of this city to mater upon Urs
r W ahovo(We) gree to any for imnit yan keep ha
(We)agree to rave,indemnify and kith harmless thew City of Cupertino against
rq inconsequnce ofueerasing granting of a.Nh. may in any way scene againstraid City
U 2 inconsequence
AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat
SOURCEULA NS. :S4 of
� Re-roofs
ignawrc o ncmr MATE IALS DISCLOSU Data Type of Roof
Will Ne applicant o lumbuildin currant sten or handle hmardous material
az ri.Seaved by Cupeniu Munici ode.Charm,9.11,and the Health Safety
cnJedeson zsthe and
Yu s3zan All roofs shall be inspected prior to any roofing material being installed.
[e
Will the applicant or towns building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
istrict? �y
❑Yes /N.
1 havc m W Ne h=di)usmaWdals nyuimmenm under CMpur 6.95 of Ne Califon
nu HcalNlk SafctyCode,Sccsom25%5,25533md25534.lund mwdthuifthc Wilding
J.ea not currency ham a snot Nat it is my responsibility w misty the acupmt of the
o,trannum which el pd am«ora Ceorpaato of Oce.n eY Signature of Applicant Date
s /3
Owner or aamoriacea m All roof coverings to be Class "B"or better
, x Community Development
10300 Torre Avenue
i1 Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building De artment
JOB ADDRESS: PERMIT # o of d a
O,f 3 71
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR:
or--7' • S J�3 o S•
I am not using any subcontractors: I
Signature Date
Please check applicable subcontractors and complete the following information:
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
Owner/Contractor Signature Date
ti
CITY OF CUPERTINO
« � TEMP POWERCITY OF
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$CUPERTINO PERMIT APPLICATION FORM
APN # .� z- 04_ co C� Date:
Building Address:
Owner's Name: Phone #:
Z-J01V rJ/ L,, c/
Contractor: Phone: License #:
y a� c�O !tea. 390 . wiz rj 74
Contact: Phone: Cupertino Business License #:
�via2 �� k�v�c gid'•390. s/z .
Building Permit Info:
Elect -X
Job Description: Ae
Residential Commercia ❑
Cost of project: a�
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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