05070159 n� CITY OF CUPERTINO �'
BUILDING ^DIVISION PERMIT CONTRACTOR,INF;ORMATION q ,
BUILDING ADDRESS: ,s A PERMIT NO.
:sop
HENRY LO 05070159
NER'SNAMIi ,S" 'PERMIT MUE DATE
T4RNRV T.0
NE: SANITARY NO. CONTROL NO.
I
ARCHITECUENGINEER: BUILDING PERMIT INFO
a.
BLDG /{ ELECT PLUMB MECH
too LICENSED CONTRACTORS DECLARATION •P•
Job De5Cr1 tlpn ww
� FF 1 Mreby affr Thal 1 am 1 read undo pmvrsiom of Chapin Y(<a inencing P '
il`3 wtUSem n7QV11afDrviswn Jofthc BuinmadProfessiom Cock and YliecnS ix T: - ,I `�`V i
^ y In full Tomend eRcm,'Z X ;J- i d"
�i Luae.Cl az '''-' 1^+• '-' L .a :,INSTALLING TEMP POWER' POLE
p Dale 2 ARCHITECTS Contractor
DECL
'J` -.rt ,..-.'• s shallxuse DECLARATION U//I VY` ✓
1 1 undersand my plans shall M used u public records
1.0 u.h Limmcd Professional • G"k+b ( `��,
Og (' •rry OWNER-BUILDER DECLARATION
iZ ;I 1 hereby affirm Um 1 am exempt from the Contracmfs License Law fur IM tad
o O fallowing mason.(Section 703 1.5,Business and Professions Code:Any city or county
<$ which requires a Permit to construct,altar.improve,demolish,m repair any structure
ll¢i prior to is issuance,also matures the applicant for such permit to file a signed Mummer
that he is licomed pursuant to the provisions of the Contracturs Limmse Law Chapter 9 Sq.Ft. Floor Area Valuation
Y~S (commencing wi th Scclion 70M)n(Divuion 3 of the Business and Pmfmiom Code)or
5.. that he Is a..pt Ocrefrom and Be baso for the alleged exemption.Any violation of /Av•c a�x.PIAyk.
Sec ,3 tion 7031.3 by any applicant for a permit subjects the applicant to a civil Penalty of NUf Eer 0 0 Occupancy Type
not more than five hundred dollars(5500).
e wi 1,as;owner of and
pmpcny, m is employees with wages az their Sic compensation,
will Pr the work.andthe he Con isnot,tended Livens,Law t font apply to in Business
and eny who
Code:The ms Consomme, nd who Taw aces tors apply w an owner of Required Inspections
own em whobuilds orimproves Uercon,and who dmsxuch work himselfedthrough his
ownemployers,Provided pr such improvementarenot inkmkdmpleered for sale If,
builder ,Nebuildingorimprovementis=to within one year or completion.due case of
builder will have the burden of proving Um be did not Wild or improve for purpose of
sale.).
E.1.as owner or.Oe property,am exclusively contracting with licensed metro rs to
construct the pmject(See.7044,Business and Professions Code:)The Contractor's Li.
cane Law docs not apply to an owner of propcny who builds or improves Uercon,and
whocontracts for och pmject with a c(musKu Ks)licensed pursuant w the Contractor's
Lice Law
EI . ,
rept, c.
ei See. _
A.. C 'S 0!1 SATI TNDECI:ARATION
1 hereby affirm under ally of perjury one of the fallowing declarations.
I have and will maintain NOcas,of Consent to self-insum for Worker's Compen-
salon,as provided for hy,S ion 37W of the Labor Codc.for the performance of the _ ,-
work for which this permit is issued. r13
E 1 have sad will maintain Worker's Compensation Insurance,as inquired by Section ..
37W of the LaborCode,for the perfoim oce of Ue work far which this permit is issued. ,
My Worker's Compensation Insurance cannot and Policy number art:
Cartier. Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crna section recd not hecompleted ifthe permit is term=hundred dollars(SIM) ,
prima)
I moify Out in the performance 0m work for which this permit u issued.I shall nut
employ any perS ny man azlo enmlk Workeri ompe ` n
Laws
of California.
Applicant
NOTICE TO APPLICANT If.3 cr m this Ccnifimta of Exem,jilon.you s ould
homme suhjcn so Uc Wortcr's Com tion pmvisiom of the Lahnr Coda,m must
thisrmmvo
.,O forthwith with such provisin peitxhallkdccctlmked. -
Z CONSTRUCTION LENDING AGENCY
[•• Ibotchy affirm Oat there is a construction lending agency for the performance of
fY' the work fur which this permit 6 issued(Sec.3M.Civ.C.)
Q A Lender's Name
CL Lender's Address -
Z
U Q I anee Un 1 have mad this application and sink Oat the sMvc ors misting is
correct I agree to comply with all city and county ordinances of and some lows relating to
Q U alowngcruiond omand heabyamhodmmPrnknatiwa of this city mcntar upon Uta
CLI slave-(Wo) gree to anyave rot indmnify an keep ha
FG (We)agree It save,indemnify and keep harmless Bitw City of Cupertino against
'fA liabilities.judg ents.costs and cxpcmm which matin any way attruc against said City
fJZ in conrtqucnc ofthc granting of On permit.
APPLICA NOERSTANDS D WILL COMPLY WITH LL NON-POINT Issued by: Date 2�-O
E E LATIONS.
fib Z�l
Signature A ca V k
Re-roofs
N nR U$MATERIALS DISCLOSUR Type of Roof
Will d, applic n or
future building occupant store or handle Wom ous material ,
az defined by the Cu ao Municipal Codc,Chapter 9.12,and the HWO and Safety '
c,Section 25532 All roofs shall be,inspected prior to an roofing material being❑Yes /pNt P P Y g g installed.
j 'If a roof is installed without first obtaining an inspection,I agree to remove
Will Oe applicant or future building occupant use equipment or devices which
4�.l
ih' dx air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
0 N
teal Ue hvallous ma¢dau ayuimmenk under Chapkr6.95 of dk Cahfor-
afcsy Codc. - m25505.25533 acd25534.1 umbrs tlU itftM Millingndyharts¢ a thnt it h my responnihilit ndythemcusolofthe
whichmu t dorwissumccof.Cccnifc �gt�tc. Signature of Applicant Date
ori,= gent U l ink All roof coverings to be Class"B"or better
CITY OF CUPERTINO
TEMP POWER
CUPEkTINO PERMIT APPLICATION FORM
APN # ✓ Date: 717-
7- Li9-
i
Building Address: /D/ /
Owner's Name: / Phone #:
(�O 40 - X9/-37
Contractor: % Phone: n License #:
Contact Phone: Cupertino Business.License#:
Building Permit Info: f fee. / I
Elect
Job Description:
Residential Er Commercial ❑
Cost of Project: 9a
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING