040200061
CI"CY Or CUi'ER'1'INO
' '"
BUILDING DIVISION PERMIT
' CON3'RACroTORINFORMATION.'
ORgN
s3e°lvin.. ,.Trey .. t iyS�f3aa...
BUILDING ADDRESS:
PERMIT NO04020006 4020006
OWNER'S NAME:
P -RI HT LSSUE DATE
NE:
SANITARY NO. CONTROL NO.
ARCIBrTECT/ENCINBER:
BUILDING PERMIT INFO
BLDGELF.CI' PLUMB MECII
G� 0 =
LICENSED CONTRACTOR'S DECLARATION
Job D05CTIpIIOn
I hereby affirm than 1 am licensed under pmviaions of Chapter 9 (commencing
with Section 7") of Division 3 of the Businessland Professions Code, and my liceom is
in full fore and trite=LTEMP
POWER POLE
License Clan Lic. N
Dam Cr
ARCHITECTSSDECLARATION
FINALE®
I understand my plan, 'hall he used as public records
' FEB 0 5 2004
Lleeard Profeai„nal'
OWNER -BUILDER DECLARATION
I hereby I em exempt from the Contractor's License Low for the
. SIO on 703 and Profession, Code: Any city or county
recon. (S.it
t, atuss
t sae, demolish, r sig any dfemure
which rtyvs a permit m cnnswn, pinto int
which
poormits issuance. for su e a statement
require theapplicantOf for such Permit totes
Sq. Ft. Floor Arca nation
ensedpalso
thathe the Law
wit purction7
) of Diviormnf
eBusiness;Licenselsw(Cedle)Y
mencing Oismiofrnnhcegedaernid Professionslation of
(commencing with Section
Out heti. ...It therefrom and the baso for the alleged exemption. Any violation of
and
32d1D1j-bi"er00
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not or. Nan Ove hundred doll... WOOL
❑ I, u owner of the pmperty, Or my employees with wages is their sole compensation,
ns
Required Inspections
ti
will do Nc work, and due structure is not intended Or off.md for safe (Sm. toaL Business
and Professions Code: The Conuactori License law does not apply to an owner of
p
property who builds er improves thereon, and who does such work himself m through his
own employces, provided that such improvements are not intended oroffefed for sure. IL
however, the building or improvement is mid within one year of completion, the Owner -
builder will have the burden of proving that W did nut Wild or improve for purpose of
sale.).
0 I, as owner of d,e property, am exclusively convecting with licensed commotion to
consumer the project (Sec. 712,14. Business and Professions Code:) M Cuntracmrs Li.
cense law docs not apply to an owner of prpany who Wilds or improve themon, and
W canvicu for south projects witheconvrtor(s)licensed unuaad to the Convanpf'.
0. Law.
e lam mtunder See. ,Bk P C for this rearm
Owner Dam Z O
WORKER'S COMPENSATION D RATION
.by aMo. not, penalty of perjury pee of On toll i hntioe:
haus and will maintain a Certificateof COMM m mlr.insum fm Workers Compnw
senior, as provided for by Section 3100 of due, labor Code, for the performance of the
.,it for which Nis permit is issued.
❑ 1 hoc and will maintain Worker's Compensation Insurance, a refuted by Section
37W of she Labor Code, for the Performance of Or, work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Camim: Pot icy, Nd.:
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
Mis section seed not tecanpletud if the permit Isformuc hundred dollars (HOO)
less)
I cenif Oat in the pcffil m sam of the work fm which this permit is blood. 1 shall not
employ mianymadin ssLe�g.clffnt subject o the Worked Compensation
Laws of Ca, o AAte
-
Applicanty'
NOTICE P LI T: If, otter making the Ccnifi of Excmpuan, you should
Wcomcl cm to the Wofkcra Compensation pmvisionsoflhc LeWr Cndc, you mum
fonhw comply with such provision or this Permit hall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby arfirm that there is a construction lending agency lot the paffufor mce of
IW work for which this pefmil is issued (Sm. ID 7. Civ, C.)
Landers Name
I-coulma Address
r 1 certify that I have read this application and state dust the salve Information Is
correct, I agree to comply with all tiny and county ordinances and state laws relating to
r Upon th.
nd hereby
oforlikelois coyroemm�o
building ce)agrei
above-mentioned property for inspection purposes.
ad
to,aw,indconsfy eephou lesesof
( ago
(Wc) agme to save, and expen and keep ay in an w City of Cupertino against
i may in any way mrnm against said City
liabilities,judgments,the
mm, of his iswhtch
in of this permin.
A cPLICANTe of UNDERSTANDS COMP KITH ALL NON -POINT
T APPLICANT UNDERSTANDS ANO WILL9
Issued by: Date
_
S GULATIONS. la/ `0
'_1•t, ]'H
Re -roofs
Type Roof If
morApphcoHAlEARDOUSMATEA
7Damgn
DISCLOSURE
of
Will the applicant or future building Occupant store or handle harardous material
az defined by the Cupenin0 Muni ipal Codc. Chapter 9. 12. and the Health and Safety
.
Code.Sectionl! 32(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Ye No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant of future building arupant use equipment or device which
I, horardnus air contaminants as darned by the Bay Area Air Quality Management
all new materials for inspection.
smia?
❑Yes Nu
[have rtaJ Ne hvafdmmsmatcrials requirements under Chapmrli95 of the Califor-
nia HeslNdt Salty Cudc, Sections25505.15533 and 2553d.I undoes nd thd ifde Wilding
Jpa not curtcntly how a nn.nl thus h is my mspomihilit 'howy de arupmul of the
req. c IncharmdWmet urtossaimcuOr 'fitit r_� sdoffy.
Signature of Applicant Date
`--
All roof coverings to be Class "B” or better
Owner or amm�rized agemn bam�
CITY of
UPERTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
0
D Z O u0 X�
APN # 2,6
1 v
ELECTRICAL
Date: a/a/o LL
Building Address:
;2,r.,g03 F-1 A-A)F- S)
DQut C X40 CSA- ` coi L( -
Owner's Name:�����
)64Phone
#:
C4(_o6)a3a--eus6
Contractor: _
j. it
Phone:
-kXF_
(Soo) 3So-3731
License #:
Contact: _
, M
Phone:
tl`\ 3So -3�3 I
JI
Cupertino Business License #:
Building Permit Info:
Elect ❑
Job Description:
Residential
Commercial ❑
Cost of Project:
00
zso
•
Qty. if
Fee r)escrintion
Fee Groun
BTEMP
TemporTj Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
a
x"93. �a-