05120147CITY OF CUPERTINO�;
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TNOt1VIQN:
BUILDING DIVISION PERMIT
;G"WNTRAQyR
BUILDING ADDRESS:
D & D CONSTRUCTION
PERMIT NO. 05120147
OWNER'S NAME:
FERMITISSUBDATE
MOK SAMMY L AND JADE M TRU?TEE1447
HMPTON DR
12/23/2005
NE: -
SANITARY NO. CONTROL NO.
408)666-5298
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BO EO PLO MECH
O
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hreby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Div Won 3 of the Business and Profession Cade, and my license is
I.f r andeGect G
TEMP POWER POLE
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ARCHITECTS DECLARATION
DECLARATION ON
1 underwnd my plain shall it used as public rtcnNs
✓may .
Licensed Professional
OWNER -BUILDER
mDECLARATION
I hreby .(Simi Net 11- exempt from ban Cantrauh License Law for the
c
whmving mason. (Section ](DIS, Business and Rvfeasiues Code: MY an or county
which requires •permit demul W, sig atrocmn
ct slut impramnt
1
fie a ed
pd«wits censed),alsomq use tie applicantforpermit w Ole•signedsuument
o trim t for such
pursuant7000)ofDislamofWescawcwraua«atdonC
Sq. FL Floor Area
lua[ion
mo memin wi of 3 oft he Budneoand mm)m
viCtion
(comm encingwithheniourn
d --
bandis f on. My of
Nat h u exempt thmefrom and We bots f« the allgnd exemption. My violeUon of
and
S
F
icy Type
Section 7031.5 by any applmam for a permit subjects the applicant to a civil penalty of
sot mart dun five hundred douses (5500).
❑ 1. as, owner of to propmsy,Or my employees with wages u their sale compeno0on.
Required Inspections
will do the work. and the structure is not intended «offered for sale(Sec. 7044, Bmhesa
and Profession; Cade: The Contractor's U.. Law dem rot apply In an owner, of
property who builds or improves dereon, and who doss«h work himsel f or through his
own employees, provided that such improvements an, nothanded «offered for ale, IL
however, the building or improvement is said within ane year of mmpledan. the ower.
Wilder will have the burden of pouring that he did rut build or Improve f« purpose of
ale.).
❑ I. as owner of the property - .m exclusively contracting with Headed mn0alon In
c0muuct the project (Sec. 7004, Business and Professions Cade:) The causation U-
nae law does not apply in an owner of propeny who builds or improve theman. and,
who com acts far such projects with. cantraror(s) licensed pendant in the Cmunscnr's
Lice. Law.
❑ I .m exempt under sac. . B & P C for 444 won
Owner Date
r
WORKERS COMPENSATION DECLARATION
I hereby salon under penalty of perjury ane of the following sclaradons,
1 ham and will maintain a C)Wfiate of Conant 7o self-insum for WarkehCamped.
ation, u provided for by Secdon 3700 of the Labor Code, f« the peRmmance of the
,
work for which this permit is mooed.
❑ 1 have and will maintain Wodrer's Compensation Insurance, u required by Section
3700 of the Labor Code, (« the performance of the work for which this permit is bound.
My WOrkets Compensation lnsunna artier and Policy number aou:C) W78Z
Callr. V�et t ( policy No.: �_
CFRTIFP17ON FROM WORKERS'
COMPENSATION INSURANCE
(Thu mann need not h completed If the Permit Isforane hundred dollars (SIM)
«lea.)
I certify that In the performance of the work for which this Permit is Issued. I shall nes
employ any person in any roomeran as in become subject to the Workers' Compmacadon
Laws of California, Dan
Applicant
.
NOTICE TO APPUCANT. If. after making this Cenlfican or Exemption, you should
become subject in the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he dcemad revoked.
CONSTRUCTION LENDING AGENCY
I hereby allimt that then Is a construction lending agency for the Performance of
the wok fur which this permit Is issued (See. 31197, Civ. C.)
Under's Name
,
Lender's Addmam
1 cenify that I Mw mad this application and sun that the above information is
coma 1 agree to comply with all city and county onfinances and sue laws misting in
building construction, and hereby authodse representatives of this city to enter upon use
above -m ummd Pmpcny for bnspeNan purpose..
(We) agree to an, indemnify ad keep harmleo the City or Cupertino .gamut
liabilities, Judgments, cats and expenses which may In anyway ac«ve aphut said City
in conn meme of the granting of this permit.
APPLICANT,IB9OERS7ANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
— X , I1/7 31,; -Re
_
-roofs
Type of Roof
Sipa; efAppIMVCO usew Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant w forum Wilding aceupantswre car haMk hasaNa m material
as defined by the Cupertino Municipal Cade. Chapter 9.11. and the Halth and Safety
We. Section 25531(a)7
❑Yes �No
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
Will the applicant or future Wilding aaupant use equipment or devices which
It hacardnu air contemtrunts as defined by the Bay Am Air Quality Management
all new materials for inspection.
d met?
❑Ya f No
I haves mal the hoaNnas ruse iaisregwrcmenu under Chaper6.95of the Glifor-
nulkalth& SafetyGode.S«7i«;25505.25533 andM334. 1 uMcrnuat thairthe Wilding
dos riot.une. fly have a tenant dem it is my maperuibiliry to notify the occupant of de
mgwe which amWmntpdorwWuaueofacertifiamof cupaney.
Signature of Applicant Date
Z'i7 2
All roof coverings to be Class "B" or better
OwXr
or aothoirzd agent Date
N
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS: NO 36-
PERMIT
0
OWNER'S NAME: b C
PHONE #C4 --F Y�9 • 087
GENERAL CONTRACTOR: r uJv.-
FAX # —
I am not using any subcontractors: / 2,12
Signature Date
Please check applicable subcontracto s and complete the following information
60
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing,
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
[]ESheet
Rock
Owner/ Contractor Signature
Date
Q�.
CITY OF
UPERTINO
CITY OF CUPERTINO
TEMP POWER.
PERMIT APPLICATION FORM
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APN # 2/
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Date:
Building Address: l �G a 1-
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Business License
Owner's Name:/l �C
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Phone #:
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Contractor:
Phone:
License #:
Contact:
Phone:
Cupertino Business License #:
Building Permit Info://� // yy-
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Job Description:
Residential X1Commercial
❑
Cost of Project: �J J
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Qty. if
Applicable Fee ID
Fee Descrintinn
Fee Gmun
BTEMP
Temporary Power
ELECTRICAL
/ EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
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