04030049 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �cc� '1c1taG; oxY�vU2MTrU�:°','
BUILDING ADDRESS: PERMIT NG0 4 03 0 04 9
21 E; M1 CREST PT
OWNER'S NAME: PERMIT MIH DATE
ROBLES
10NE: SANITARYNO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p
Y00 LICENSED CONTRACTOR'S DECLARATION Job Description
I bemby affirm that I am limesed under provisions of Chapter 9(commencing p
with Snclim7tBl01of DlA.mr3of NCBuainma dProfcssitsns Co de,andmyliemaeis
Wrmlfarm e dg a 78y3 p / TEMP POWER POLE
j Z License Clan Lie r
me C. r CONTRACTOR: PUROFIRST CONSTRUCTION
t- R HITEC's0TION
'Sy I my Iseda ,If.remedi
3 u� Licensed Professional
305 by� 0 NEm exempt
DECLARATION
ConTION
10 I hereby l(EUl at 11. exempt s an dm COtions a Llcenu Law for the
Soo following moan.Permit
1 7 punter Guiness and Improve.
Predications Cadc:Any city or county
u�$ which to asm a permit re cores the almc improv,demolish,ri e pair any Structstatement prior 10 to iensdpursucoquina theapplicantof
such Permit 1ofiles Law mmmem
F�F�o (thad comms llmnwit pursuant to me of Division(the Cantmcmra Lironselaw(Cheptm9 Sq.Ft.Floor Area Valuatio$1500
C (comeis'exampth Section7M)and of Division3 of thecgcd exemption.
Desion.AninnaCmle)or
.. that be u eempt therefrom utl the beau far Ne alleged eaempdon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($50(r).
I,uownerofthepmpmy,ormyemployeewithwegeudmirmlecomPeuadm, 35626026 , 00
will do thewodt and the sticture isnotinsendedoraffared fmaale(Sm.7044,Business Required Inspections
and Professions Cash:Th.Cmarsee e,Limner e Law doat apply to an owner of e q P
property who builds ornament thereon,end who does such work himself or through his
own employees.provided thatsuch improwmenssare not inmaded oraEereA ferrate.if,
however,Ne building or improvement is sold within one year of completion,Ne owner.
builder will have Ne burden of proving that he did out build or improve for purpose of
Sam.). qLe
❑st u owner of the property em axdeiv and
confessions Cod licensed comuacmn W
cense La the project apply
o x4,owner
of aotl Profesiana Code:)The Cs therson. nd
cense Law dors not apply W an owner of proper(who builds or improves thereon,and.
who contracts
for such projeca with acanuacmr(q licensed pussuanualbe Convatore _ MA ] Q p
2004
Lima.Law.
❑lam exempt antler Sec ,B&PCfor Chia moon
Owner Data BurLu1NG
WORKER'S COMPENSATION DECLARATION
I hereby affir under penalty of perjury ow of dm following declarations:
1 have and will maintain a Certificate of Consents self-Insure for Wo lm'sCompm-
Saila^,u provided for by Section 3700 of the labor Cade,for the performance of the
work for which this Peri,is issued.
❑I have and will maintain Worker's Compensation insurance,u required by Section
3700 of ch. Code,for the performance of the work for which this perk is Issued.
My Wme:r'a Compam.fion Insurance carrier and Po' numberare:
Carrico: y Iicy No. ���• a
CERTIFICATE OFEXE! ON FRO W S'
COMPENSATION INSURANC
(This uNon mod nmbocompmmd if the permit Is fortune hundred Wdum(SIM)
nr Icer.)
1 certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manneru as m become subject to the Worker)Compensation
Laws or California.Date
Applicant
NOTICE TO APPLICANT:IL after making Nu Certificate of Exemption,you should
We..subject W Ne Worked Compensation provisions of the labor Cade,you most
.J O foMwim comply with ma provisions or this Permit shall be deemed revoked.
Z y CONSTRUCTION LENDING AGENCY
F-t T hereby SM.that them is a emo^acuses leading agency for the perfurmana of
�i7 the work for which this peril is issued(Sec.3097,Civ.C.)
W� Q Lender's Name
z Lenders Address
V Q I certify Nu I have mad this application and salt Nat the above inforadun is
Cy F caret.I agree to comply with all city and county aNinsness and sate laws raising to t
0building construction,and hereby authome mprescnmives of this city W enter upon the
U above-mentioned property for inspection Purposes
Ly�,LL (We)agree to Save,indemnify and kap harmless the City of Cupertino against //)
r`„t V7 liebilitles,judgmena,casss and ex pensee which may in any way seems against said City
L)z in canugmnce of the ting of this peril.
�--� APPLICANT UN ANGS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
URCE REJ TI S.
Re-roofs
arc of ppli UConum Oe
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wr applicant orfuture building mcupanetom or handle hrrsedaus material
ss defined by the Cupertino Munic+lp I Code,Chapter 9.12.end the Health and Safety
ads,Section 25532W All roofs shall be inspected prior to any roofing material being installed.
❑Yea
Will the applicant or velum building occupant s equipment ar devices which If a roof is installed without,first obtaining an inspection,I agree to remove
it haerdaaa air aataminana a +wtl by the Bay Arca Air Quality Management all new materials for inspection.
it ha
❑Yee Nu
I haw mad the hmardo� aoil s requimmcnss un der Chapmr6.95ardWCalifor-
nia Hulth dr SafctyCade,Scp1 255(15,23573 end 25534.1 and emend thwifthe building
oa
does t currently haw a ruv� 4 that it u my responsihility W notify Ne mcumm of the
requiremsna which So b nal R[i.11.ar om of a Cco,law of sap ncy. Signature of Applicant Date
Owner or an cot but. All roof coverings to be Class°Br or better
Community Development
10300 Torre Avenue
aClOF
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408)777-3333
UPEI�TINO
Building Department
JOB ADDRES,9tq PERMIT #a It U
2t Ovw
OWNER'S N , k PHW # 6;; 3.G
GENERAL CONTRACTOR
I am not using any subcontractors:
gnature ate
Please check applicable subcontractors an com Tete the following information:
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
Sheet Rock
Tile.
t 3
Owne Contractor ignature Date
CITY OF CUPERTINO
'
SLIM&
TEMP POWER I
UPERTiNO PERMIT APPLICATION FORM
APN# � ZG a �/ Date: �
Building Address:
Owner's Name: Phone
LS d /�, /� �`� 22� - S o
Contractor:Yo rs f' Phone: License#:
Cont ct: Phone: Cupertino Business License#:
14'Al-1
Building Permit Info:
Elect ❑
Job Description:
Resident i Co, ercial ❑
Cost of Project:
•
Q
A Iii a e Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
-2, 77
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