11070021 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: N STELLING & HOMESTEAD RD CONTRACTOR: MT2 TELECOM, LLP PERMIT NO: 11070021
OWNER'S NAME: PACIFIC GAS AND ELECTRIC CO 3780 COMMERCE DR DATE ISSUED:07/05/201 1
OWNER'S PHONE: 4153089400 W SACRAMENTO, CA 95691 PHONE No:(916)376-8555
LICENSED CONTRACTOR'S DECLARATION '-
13UI1,DING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic # 7 cl CJ 1 — --
MECII RESIDENTIAL COM:v1ERCLV.
Contractor / I e'��„ p h-7 Date ��
1 hereby affirm that I am licensed under the provisions of Chapter 9 '1013 DESCRIP 1 ION INSTALL FIBER MODEM 130X INI'O AN F:XISI'ING C'f[I.I.
(commencing with Section 7000)of Division 3 of the Business& Professions SII 1.
Code and that my license is in full force and effect.
POR T-M013IIT WF.SICORI'
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate ofconsent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. APN Number:32607035.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,
uction,and hereby authorise representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit Additionally,the applicant understands and will comply Issued : Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date 7-J-- All roofs shall be inspected prior to any rooting material being installed. If a rool'is
installed without first obtaining an inspection, I agree to remove all new materials for
OWNER-BUILDER DECLARATION inspection
Signature of Applicant:_ Date
.ereby affirm that 1 am exempt from the Contractor's License Law for one of Si`g
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A”OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1.as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE.
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent:
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If;after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions ofthe Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec 3097,Civ C)
Lender's Name
APPLICANT CERTIFICATION Lender's.Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
Signature Date