03070015CITY OF CUPEWHNO
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BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:,':
BUILDING ADDRESS:
PERMIT NO0 3 0% O O 1 S
OWNER'S NAME:
PERMIT ISSUE DATE
ONE;
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTO R S DECLARATION
Job Description
I hereby affirm that I em licensed un r mvisiom ofChapterCode, 9 (commencing
P
er Division 7of Ne Bassin end Professions Code, and my license is
withSectionI...
pli
License clean act
TEMP POWER POLE
ear Lle.a
Date Contract°
CONTRACTOR: MARGADO-4 CONS, p�
/,
yr understand my gl ne.hull be used n public rreemd
Licensed Professional
OWNER -BUILDER DECLARATION
,II II S 2003
1 hereby ,(firm that 1 am1. exempt from the Contractor's Law for ,s
Any
]831.6. Business and : counts
Cade: Any city
following reason, c
improve. ternm
structure which requires a pcmit m consumer, aline impmvc, dcmnlish, or repair any nmcmrc
Permit t s
g.t g G
prions its issuance, also requires is applicant for such Permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
—� va se
Sq. Ft. Floor Area Valuatio,�500
(commencing with Section ]1100) of Division J of the Business and Pmressions Gale) or
that he Is exempt therefrom and the basis for the alleged caemp,ion. Any violation of
3. BT4QLIDT'(3er00
Occupancy
P Y Type
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil Penalty of
not mom man five hundred dollars ($511)).
❑ 1, as owner of the property, or my employees with wages as their axle compensation,
will do me work, and On smooth, is not intended or offered for sale (Sec. 7W, Business
and ProfessiuM Code: The Commerce. License law dors
Required Inspections
not apply to an owner of
progeny who builds or improves thereon, end whe doeuuch work himself ser through his
10 3 - UFER
own employees, provided that such improvements are nor intended m offered for sale. If,
304 — ROUGH ELECTRICAL
however, the building or improvement is sold within one year of compledon, the owner.
,
builder will have the burden or proving that he did not build or improve for purpose of
sale.).
I, as owner or she property, am exclusively contracting with licensed contractors to
construct the pmjec, (Sec. 7044, Business and Professions Cade:) The Contractor's Li-
cense law does not pply to in owner of property who Wilds or improves thereon, and
who contracts for such pmjecu with a comramar(s) licensed pursuant to the Characters
License Law.
❑ 1 am exempt under Sec. B & P C for this moon
her Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations:
I have and will maintain a Certificate of C . . . t to self-buurt for Worker'. Compere
-
ution, as provided for by Section 3700 of me labor Code, for the Performance of the
work for which this Permit is issued.
ve and will mans in Worker's Compensation Insurance, u required by Section
J a, me perfa cc of the work for which this Ismail is issued.
My Wor s oa In re 'entad. Pylipp)um r rt_
int, Poh y No.:
-
C RTIFI E OF EXEMPTION FROM WORKERS'
MPENSATION INSURANCE
flTissection othcchmpleted Rthercmd isforoachundh,ddhllam(SIM)
or less.)
1 tend ry that in the perfomanes of dee work for which ,his permit is issued, I shell not
employ any Person in any manner an a to become subject to is Workera' Compcnsadon
Law. of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exem pion, you should
become subject to the Worker's Com re notation provisions of flue Labor Chile, you main
fonhwi,h comply wins such provisions or this Permit hall ba earned revoked.
CONSTRUCTION LENDING AGENCY
I smarty affirm that them is a consmdinn lending agency for is performnce or
me work for which this permit Is issued (Sec. 309], Civ. C.)
Lender, Name
lender's Address
I cenify that 1 have mad this application and sum ma, the above In(omuiun is
COMM. 1 agree m comply wide all city and county ordinances and state laws relating to
building construction, and hereby authorim rtp¢aro utingi of mi. city to enter upon the
abevc-on.od lnad property re Inspection pope..
(We) agree to ave, indemnify and keep hamlcu the City of Casper ino against
liabilar,judgmenu.cosu dexpeese.whichmayinnywayaccmcagainuaaid City
.�
in rase are c tin this Permit.
A LICA STA AND WILL C P WITH ALL NON -POI
SO ION r,7,, 0
Issued by: Date"
Re -roofs
Type of Roof
`
S' ort pPhead, on" or Dam
HA R O MATERIALS DISCLOSURE
WillmcapPlicamor las building,ecupanl nnrc tar handle hanNuus maurial
Is donned by the Cupenino nicipal, Code. Chapter 9.13, and ,s Health and Safety
Cote, section 35533(a)T
❑Yes Ail.
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 building occupant use equipment or devices which
harardoua air contaminants u defined by the Bay Area Air Quality Management
all new materials for inspection.
uinT
❑Yes A.
1 have mad the hamrdnus materials requirements under Chapter 6.1)95 of is Califor.
nix Health&SafctyC SclauM505,3553 J 34.1 undo isnd duoifde Wilding
mend not broil i. m spoesi ly to nndfY the occur", surdas
mquircmc ionto met dor is ,,race camefQgc_pn� �-s
!�
Signature of Applicant Date
/D„tee
All roof coverings to be Class "B” or better
Own
nth ,ed as
Zydrl
�CUPEI,TINO
I
CITY OF CUPERTINO l�
TEMP POWER 6 3 ° 70
PERMIT APPLICATION FORM
APN #
o i
Date: V d3
Building Address: 1551
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ul1, cm
Owner's Name: G V
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Phone #:
Contractor � IO — �
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License #:
Contact: ��� n ^a
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honer �� �O
Cupertino Business License #:
Building Permit Info::
Elect
Job Description:
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Residential
C mmercial ❑
Cost of Project:
Qty.
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Annlii6ahle Fee ID
Fee Descrintion
Fee Groun
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING