03080158BUILDING DIVISION PERMIT
I^ ^rt ^UUtr= ^ ^ K & M DEVELOPMENT INC IfertmnnrsV03080158
I hereby almrm that I am licensed under pct
with Scctipn )ry,)) of Division 3 of the Businns and
in full fo effect.
Liccnu CI s _..G Lic. p —
2 a M I hereby affirm that 1 amxe pt rr he Contractor's License Law for the
OO following reason. (Section 7031.5, mass and Professions Code: Any city or county
<2 � which mqui1e5 a permit m conswcl alter. improve, demolish, or repair any atm use
0 Z i prior to its issuance. also noes irm the applicant for such Permit o file a signed sulcmcnt
1s that he is licensed pursuant to the provisions of UC Contractors License Law (Chapter 9
EI -a fcommencing with Section 7000) of Division 3 or the Busincas and Praressiona Core)or
that he is exempt Wrafrou and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit ands cat the applicant to a civil penalty of
not more than five hundred dollars (S500). - -"—
El 1, m owner of the property. or my employees with wages as their role compensation,
will do the work. and Bac strvcwm is nm intended Or offered for sale (Sec. 7044. Business
and Professions Code: The Commerce. Liccme law does not apply to an net of
property who buildsor improves thereon, and whodacs such work himself or through his
own employees, pmvidcd that such improvements are not intended or offered for sale. If.
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sok.).
0 h as owner of the propcny. am exclusively contracting wit liccmed convectors to
construct Be project (Sec. 7044. Business and Professions Code:) The Ci nvaccer's Li.
come law does not apply to an owner of property who Wilda or improve daemon, and
who contracts for such projects with a contector(s) licensed pursuant to the Contractor's
License Law.
[D1 am exempt under Sec. B & P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pemlty, of perjury, one of the following d,aboatiom:
I have and will minimal a Ccnificzm of Consent a self -insure for Worker'sComyen-
tion, as provided for by Section 3700 of the Labor Code, for the performance of the
wark for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, a required by Section
3700ofthetabor Code.fw th performance ar the or which Nn rmil isissued.
My\Warke Compensation lmunmx ex/t,rya, and Pol' number
C.
C. mC0 •l� CO'�3Y.iPoln No.:
!!
CERTIFICATE OF E% EM PDON FROM WORK ERS'
COMPENSATION INSURANCE
(This reenact need not he completed If the permit is for one hundred dollars (2 mal
ser lCSa)
1 certify that in the performance of the work for which this Permit is issoetl, I Mail not
employ any person in any manner an as to become subject o the Workers Compemation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of Ile labor Code, you must
D z ronhwilh comply with such provisions or this permit shall be deemed invoked.
zO CONSTRUCTION LENDING AGENCY
1 hereby id irm that there is a comtruainn lending agent, for the performan¢ of
y the work fur which this permit is issued ISce. 3097, Co. C.)
21 Q Lender's Name
1 Lender's Adduces
D
Q 1 comfy that 1 have reed this application and aux Nes Bic ninon information le
L F, conch. ) agree to comply with all city and county Ordinances and stale laws relating to
�UWilding contamination. and hereby aufhprin represenlxti.ins of this city to toter upon the
W above-mentioned property rot impaction purposes.
L y (We) agree to save, indemnify and anal harmleas the City of Cupertino against
fA liabilities,judgment, costs and expenses which may in any way income against mid City
Jz in consequenec of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALt. NON -POINT
handle hazardous meterod
and the Health and Safety
ore
Will the applicant or f M. ui Wing occupant use equipment or devices which
it harardi'm air contaminants as defined by the Bay Area Air Qualify Management
rmrin7
❑rata t3N�
I have mail the hang imsmawrialsnquimmcntunder Chaper6.95ofthc Califor-
nix He th&SafctyCode. Scctiom 25505, 25577 am125534.1 umlcrsland that iftW Wilding
does n e eptly bane a scrfanl that it is my responsibility so notify Ble arupanl of the
1060 WEST HILL CT I relsm r rmUh VAIL
no
(408)253-9787 1
SANITARY NC7. T�
BUILDING
Job DescriptioovA,, S„EF0
TEMP POWER SERVICE AUG L 9 2003
BUILDING
Sq. Ft. Floor Area Valuatic
'726";nn SR _ nn
APN Number. _.. Occupancv
l IJ3 - lJFEK Required Inspections
304 - ROUGH ELECTRICAL
Issued by:
Re -roofs
Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
of Applicant Date
All roof coverings to be Class "B" or better
as
ICITY OF
CUPEkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
0�? 6z0/ '8
APN # _?3D= se,
Date:
03
Building Address:
Zo ,'a'�
Owner's Name:
Phone #:
Contractor: Phone:
klg� -I. C.
License #:
12,0 (?I -t[
Contact: Phone: //
9c_
�z
Cupertino Business License #:
Building Permit Inf
�
Elect
Job Description:
1'ii✓ GL- /,'a /7 iL' �o ✓-�
Residential I Commercial
Cost of Project:
•
0
Qty -J -
AvilcgbleJ Fee ID
RPP Tlaerrin4inn
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
4 as �,?-9