04020117 r CITY OF CUPERTINO ',4 '•✓r;-..,a.,; ,c»c.r+'. .�, .'e . •F':'ala'.'=.:2:, ice.:&
BUILDING DIVISION P/ERMIT ,CONTRACTOR INFORMATION:,.
.1 BUILDINGADDRESS f.--Le-0lery PERMIT NO
WILLIAM HURT 04020117
I�T '7dn nra�ap aver' _- -
` OWNER'S NAME. PESTIISSUEOA7E
WILLIAM HTTRT 91740 ArA7AR AVE n2 /T,-�T—: 20L)4
ONE: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
20 p LICENSED CONTRACTOR'S DECLARATION
F 1 ion? aflbm Net 1 am licensed into and of Chapmr Y(commencing Job Description
Zj
to iwith Seorce and Division 3 o the Bessie.•.end Professions Code.end my license is
< n full roux and crcect
5q: in full o. TEMP POWER POLE
Contractor
omr ec _
^q�q� ARCHITECTS DECLARATION
2� 1 mdcraund my plans dull M used as public rtcorta
�yU
3
Licensed Pfm4nal o O
3 OWNER-BUILDER DECLARATION
<E 1 Wrchy.(firm oel 1 1. exempt form the feu Contractor's e:A n c law for the
a O following reason.permit t 111]13,B.&]Mr. and me.d(m.m Calf:Any my or county
$tai which regwma a permit re construct.applicant improve,demolish,of repair any swclore I C C n n
pnorto its tensedpelwnegama the Wapionso for such permit Blea signed summcnt -
��< that nwit pursuant to the provisions of the eBusinss Ltcenm law(Chepmr9 Sq.F[.Floor Area Valuation-
(commencing
ca that Ms cocwith Section 7")of Division fr ofthe.goodnessapt PmfessmnsCak)Or
l
i Net io u 31.5 b therefrom end the basis it the cis do exemption.Any violation of r-,s-s».v�.,i.n..r.
Section]than five any applicants(a Permit aubjecu the applicant to a owl Penalty of 3 51UVS III QIQ 0 OCCU anC net more than firs hundrtd dollars(3308). I P Y Type
❑i,a owner of the propeny,m my employees wM wages U them sole compensation,
will do the work,and theswctum is notin¢n4d oroReend(anode(Sec.1014,Busmen
and Pofessmns Code:The Contractor's os U.Law dos n apply to an owner of Required Inspections
propenywho buildlimimpraves thereon,andwhodcessuch wmkhimself orthrough his
own employees,provided Nat such impmaementsare not intended oroRraed fmsde.IL
however,the budding or improvement is sold within one year of completion,the ownery
builder will have the burden of proving that he did not build or improve for pury.se of
sale.).
es owner of the property am exclusively contracting with licensed contractors to
cons ct the Frahm(Sox.7W.Business and Professions Cade.)The Comosma's U.
come law does not apply 0 an ownm of property who Wilds or improves theseon,and
who contracts for such pro)ec s with a contractoKs)licensed pursuant to the Contractors
Le me law.
❑dun exam nder Sea B d:P�fCC fo''rr�thiis�s mu.n
Dose�—
W 'S dory SATION,
on Etim'to n,
1 hereby aRism under penally of perjury ore of the o ow-ling declmauom:
I hove and will maintain a Certificate of Comenl to self-msum for Worker's Compen.
cation,as pmvided for by Section 7700 of the labor Code,(m the performance of the
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as mquired by Section
17M of the Labor Code.for the performame of the work for which Nu permit is issued. l
My Workers Compensation I...carrier and Polity number art:
Card" Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ndo merit.need nos hecompk¢d if the permit is forme hundred ddtars(SIM)
to It.)
1 cemfy that in the performance of the work for which this permit u issued,l shill not'
employ any person in any manner so as to become subject to the Workers'Compensallon
Laws of California-Dam
APPlx.a
NOTICE 170 APPLICANT:If,after making this Certificate of Exemption,you should -
become subject to the Worker's Compemeuon previsions of tM labor Code,you most
ZO forthwith comply with such pmviamu or thta pemm shall be decmcd revoked.
CONSTRUCTION LENDING AGENCY -
f-' I hereby affirm Nat once is a construction lending agency lot the Performance of-
E the work for whnh this permit a issued(Soc.3W7.co,C.)
Ig1 Landers Name '
7 z L roler'sAddre-
rJ Q 1 cen ry that I have read this application ad sum that oc a1mve information is
correct I agree to comply wit all city and county ordinances and sum laws relating to
�I l Wilding.pognotiog and bemby,0.wich may to my ofy.1. rnmr upon me
4 above-menuoned property for inspeeuon purposes.
(W.)agree to sea.,tndcmnHy and keep harmless the Coy.(Cupcnnno ogvmt
Uy incur .eve of th,gren, dcapentta whmhmrymany way acme egenmtred City
C)z A consc mncc or the gmnti g of this permil.
^� APP 1 UNDERS DS AND WILL COMPLY WITH ALL NON-POINT ( Issued by Dat
SOU C ULATIO _
K 2^l�^dZ Re-roofs Q ( //
Sign oTApp rtanUC.m DO D.k /
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicantm future Wilding occupant same or and the Health muoudour
and defined by the Cupertino Mumnpe ode.Chapter 9.11.end the Health and Safety
out.Ouon 25512(a)?Yes All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining n inspection,I agree to remove
Will de applicam or future Sur upem use equipment or devices which g P g
s'`a.moos an contaminants as de a by the Bay Ama .,Quality Management all new materials for inspection.
pYea
1 hors read the hoommersmourbdomquiromenta mom'ChePmr 6 95 of the Cxhim-
noHcalo&SafetyCode,Secuo 25505.25577 and 25514 1 unacssund the if the Wdthng
dots not cunent M1.m•cone at n n my n.sImmihdity m notify the occupant of the
mgmrtments vW t rinhou ..factNre—am ofOccupmry Signature of Applicant Date
p tip 2 1�
Owner o a�ori,sdascm _ - � \ Date f All roof coverings to be Class"B"or better
CITY OF CUPERTINO
TEMP POWER
UPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address: c7 z4 n
Owner's)Name: Phone#:
Contractor: Phone: License#:�/
Con act 1 1 Phone: CupertindBusiness License#:
fA� t IIlA-r,�, (�U 2T P�SD
Building Permit Info:
Elect ❑
Job Descriptio
Residential Commercial ❑
Cost of Project:
V
Qty. if
c }� Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING