04070099 (2) CITY OFCUPERTINO
£' BUILDING DIVISION PERMIT CO�NTRAC'TQIi TN '(7t�IA'fIO y
BUILDING ADDRESS: GROUND UP CONSTRUCTION PERMIT"°04070099
SAN
LE DRO
OWNER'S NAME: hh .t n, PERMITL$UEDATE
10568 SAN EANDRO JESANLEANnRn
ONE: SANITARY NO, CONTROL NO.
(408) 910-2485
ARCHITECT/ENGINEER: BUILDING PERMITINFO
ELM ELECT PLUMB MECH
Y00 LICENSEDCONTRACX)R'SDECLARATION Job Description
u 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
" who Saetior7M)or Division 3 of the Business and professions Chat.and my license is
in bO mree and after. TEMP POWER
j License Claes Lin.g
Com
rp Dam amid m Nr
ARCHITECTS DECLARATION
z rsu
� 1 untlenJ my plans shbe used ssall public mcnrm
n
3 uLicensed Pmfesl
siane
0
OatNEon tiumDER DECLARATION
I hMaso affirm that 11. exempt from Ne Canlracmo License Law for the
p o which s i mama.(Section IDn tr Business and Professions Code:Any city nr moue J
x m which requires a .also to ennatrthel,alcor,impmse,h parry h,in repair any structure
u�'^ priamslcensecc.alsto se theapplicantof for ooh pcwilm rile a tense,Law(ned slatemcm
sharommilicensedcirg with Saidpursuant m she of Divides 3 the Contractor's Limnsc lsw(Chepmr9 Sq. Ft. Floor Area /U Valuation
of the Butrunicass oil
Net or u samba therefrom and the btu for the objects
th tl compiler.Any=of
ad,. burnbyuryepddiftfor•pewitmbjauNuapplicantmacivilpenallyof GTO0 Occupancy Type
not moa Nm five hundred dollen($500). '
I,as comer of the pmpeny or my wployces with"gas as,Nem sole compensation,
will do the work.and theshhum,is at intended a oBomd frand.(Sec.1044.Businru Required Inspections
and Professions Code:The Commerce,License Law data not apply m e ns an owner of q p
property who buildsor improves thereon,and whodoesauchworkhimulfor Wough his
awn employee,provided thnsuoh improwmanU am nut immnded oroBared for sale.If,
however,the building or improvement is old within arc Sear of completion,Ne owrcr.
builder will have the hurtled of proving that he did rot Wild or improve for purpose of
axle.).
4.as owner of the property,am exclusively contracting with licensed commerce,m
nswcl she project ISa.7W.Busmoss and Prafesmm Code:)The Commucumi Li.
tttae Isw dose not apply tem owner of property who builds or improves thereon,ant
who comet.for ouch projeeu witha eonuacmr(s)licensed pursuant an the Contactors
License Law.
01 es pt under Sec. ,Bh PC or but alIu11on .
On, Dai-111 q
7czyWORKER'S COMPEUATION OECLARATIDy�
I hereby affunder penalty of perjury one of the foil. tlec
irm Wall.ns:
have arta will maintain a Certificate of Consent to selGinsure for Workers Compcm
n,u provided for by Sermon 37011 of are Labor Code,for the perfowence of am
weak for which this pewit is issued.
hew and will maintain Workch Compensation Insurance,ss rcquimd by Section .
of the Labor Code,for the performance of dte work far which this pewh is issued.
Workers Computation Insurance carrier and Policy number am:
ier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mrs it.need ootbecompleted If the Tamil I,fromm hundred dollua($IO@
or lass.)
1 candy that in the performance of the work for which this permit Is ss.d,I shall out
employ any person in any manncrm M to become subject to the Woram Compensation
Laws of Coliforms.Oats
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the U Wr Code,you must
OZ forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-w Ihereby elfr.that Nem is a construction lending agency for the performance of
fYi> the work fur which this pewit is issued(Sec.309'1,Civ.C.)
aQ Leader's Namc
i z Lenderi Address
U O 1 certify that 1 have mad this application and sou that No shove information is
V.F comet.1 agree to comply wish all city and county ordinances and sum laws minting N
O V buildingc.swction,andherebyauthorisempreenutiwso(duscitytocmerupon(an
cS7 above-mentioned property for inspection purposes.
(We)agree to oro,indemnify and keep howler,the City of Cupertino against
fad liabilities,judgmenu,cosu and expenses which may in any way ucmc against mid City
U z In cNAWUN
of Nc grantin of Nis permit.
^� APPDER A DS AND WILL COMPLY WITHL NON-POINT Issued by: Date
SOULATI S. /
Ti I Re-roofs
Si umaf pplicoUCasoner" Oete
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will applicant or future buildingoceupantstore arhandlehuardnus material
u defined by the Caperton Munic' a1 Code,Chapier 9.12,and Ne Heslth and Safety
We,Seetian 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
NII Nc applicant or ful rebuilding aecuprnt use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit manudma air conuminanu'u dcOned by the Bay Arta Air Oualtly Management - all new materials for Inspection.
District?
❑Yes No
I have mail Ne hvvdousmaurials requirements under Chapter 6.95of vee Califor-
riaHelth A Safetycods.Seen.Z 505,25533 oil 25534.1 understand Nv ifde Wilding
rises not ay hew a tenant. at ii a my repoembility m nodl'y vee aceup.t of the
myuimmc or hichmusibc t mart Ott oft CeniEcamr \IF ay Signature of Applicant Date _
O ver oNofi argent '-Dem All roof coverings to be Class"B"or better
CITY OF CUPERTINO
D TEMP POWERCITY OF
UPERTINO PERMIT APPLICATION FORM
APN # OS o 2 Date:
/ —7 1% v u
Building Address:
1050 5&, Leardto ,w c� No (a aso,�
Owner's Name: Phone #:
N
I- N c 'los )ays-sS2
Contractor, Phone: License#:
puts uoK q16-3445
Contact: Phone: Cupertino Business License#:
i SG� "F1o �2S `fOK `110- des
Building Permit Info:
Elect ❑
Job Description:
Ees,denliaI [A Comme cial ❑
stProject:
y if
i Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
Z63 `f
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