03030117.CITY OF CUPERTINO
,''•x�� t r �"° 3i`'
"CON,RAC'�OR
BUILDING DIVISION PERMIT
INFORMATION
.
fi
BUILDING ADDRESS:
C`AiPTBGW
JM CONSTRUCTION
PERMIT NO.
PR
'S NAME:
562 DIVISION ST
PERMIT LSS A
g;
(408)379-9852
SANITARY NR3 OLNO.
ARCHITECT/ENGINEER:
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BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby Purim that 1 am licensed under provisions of Chapter 9 (commencing
with Seetirt.0010)of DivfelEcsmesa rad Profcad... Code, andmylicensel.
coln"Im��nd
p
�o�A�,E®
License K. te«
EM2
TEMP POWERS
OEC AnoN
na shall be used u lie records
- -MAR 2 5 2003 -
Licensed Pnttessioml
Licensed
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Cco recrors License Law for the
p
BUILDING
following reason. (Section 703 1.5, Business and Profession, Code: Any city at county
any nrvm
which rrquiros a permit m construct, alter, Improve, tlemaluh. m .,airnu
"
prior al its issuance.,]. requires the applicant forsuch permit to Bic a signed statement
Sq. Ft. Floor Area
v31UaCiOn
met he is llcenacd pursuant to the provismmnr thc Camrecwr. Uceoc Law (Chapter9
(commencing with Section 7") of Division 3 of me Busim«aml Professions Code) or
that he is exempt therefrom and the basis rat me alleged exemption. Any violation of
3491yyV bS0 0
- Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant u a civil penalty of
oat moe Nan five hundred dollen (5).
❑ 1, as motor of the property, at my employees with wages sm their sole compensation,
103 — UFER Required Inspections
will do thC work. and thestmmure le not intended or offend rot sale (Sec. 7044, Butsuse,
and Professlam Code: The Conmmors Liceme Law doe not apply to owner of
propertywho buildsorlmpmves thereon, andwhodasmchwmkhimselforthrough his
304 - ROUGH ELECTRICAL
awn emplores, provided that such improvements am not mended or offend fmsale.If.
however• the Wilding or improvement is old within ane year of cmnpletion, the comer -
builder will have the burden of proving that M did not Wild or Improve for purpose of
MIC.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors m
conaIntel ton project (Sec. 7044• Busion and Professions Cade:) The Contnemr's Li.
ceme law docs not apply to an owner of property who Wilds or Improves therton. and.
who contracts for such pmjecu with s contractor(s) licensed pursuant in the Cmmnetors
License Law.
I un exempt under See. . B A P C for thismason
Data
WORKER'S COMPENSATION DECLARATION
1 hereby elute under penalty of perjury one of the following dedass0onc
have end will m timet. a Cenifm.m of Consent to ulf-Inman for Worker's Compere
-
n, n provided for by Smtlon 3700 of the Labor Code, for du Performance of the
for which this Permit is Issued.
av and will maintain Workers Compensation Irmarenw. u required by Section
I have
-
3700 of heLabor Code. for Ban Performance of rise weals for which this permit a mored.
My WorkcM1 Compensation Insurance carrier and Policy number �7
olicyNo.:CO
Cartier. xfj4CERTIFICCAOTME
M
ODist
OPEFNES
-
APECOiRLK(U2t1S�'
IIN ANGW
(Thla section need not he completed if the permit is for one hundred dollars (SI W)
.
or less.)_
1 ceAfy, that in the perfumance of the work for which this permit is WO.d. l shall not
^ .
employ any person in my manner an as to become subject to the Workers' Compensation
Lawn of Califomla. Dau
"
Applicant
NOTICE TO APPLICANT: If, after making this (bdificau of Exemption, you should
become subject to the Worker's Compensation provisions; of the Ichor Code, you mum
forthwith comply with such pmviorm; or this permit shall be dcemed molted.
CONSTRUCTION LENDING AGENCY
1ber that them iss construction lending agency for the performenm of
haffum
ed Sec.
the work for which Nis permit b issued Sec. 7097, Civ. CJ
Undcrb
-
Under'. Address
I cenify that 1 have mad sols application and sum, that the a Wve information is
correct. l agree m comply with all city and county ordinances and elate laws miming to
'
Wilding construction. and hereby authorize mpreanutires of this city to enter upon the
above-mentioned property for impeetion purposes.
(We) Agree to savC. Indemnify and keep harmless the City a(Cupcnin0 against
liabilities, judgments, costs and ex Ones which may in my way aceroe against said City
in consequence of the granting it s permit.
APPLICANT DERSTAND ND WILL COMPLY WITH ALL• N N.POINT
Issued by: Date �' v
SOUR R S.
Re -roofs ''
Type of Roof
Firs, pliesn Comou r sac
HAZARD ATERIAIS DISCLOSURE
III applicant or future building Occupant store or handle hazardous material
Bred by the CuP oorm MuniWpal Code. Chapter 9.13. and me Heslm and Safety
-
Section25532(s)7r.,� /,,
All roofs shall be inspected to any roofing material being installed.
El Y" 1A
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
It hn'vakous air cnnumirc. u q( defncd by the Bay Area Air Quality Management
all new materials for inspection.
trio@
+
�_ y/1
❑ Yes
I have mad the haz«kommeuriels mquiremenl. under Chamer6.95 of the Califon
nu Hcalm@SefctyC ,Satiuu MMS.25533.d25534.iundomandfirf Wilding
Joos not currently a tanem mat It imy mapomihillty m motif ace ant of Ne
req bane ern use Ipdarto; .u.ne.isCentimes,of
Signature of Applicant .- Date
All roof coverings to be Class "B" or better
Ow r ata agern te
CITY Of
CUPERTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
63°3°"7
APN #
34
J a�_
Date: '
Z
Elect. Permit Issuance
a Q
Building Address:
Business License
-BUILDING
Owner's N e:
Phone #:
a oY\
ZhaY,
Contractor:
Phone:
-7
License #:
6-1 60.
Contact*
` Phone:'
Cupertino Business License #:
c',�
Building Permit Info:
Elect ❑
Job Description:
Residential
Commercial ❑
Cost of Project:
Qty. if ,
Applicable Fee M
FPr tircrrintinn
T7aa r nnn
BTEMP
Tem orar Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
-BUILDING
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