04080107 CITY OF CUPERTINO °E '"�t�+$. �, ,-*
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT NO.
NATIONAL CONSTRUCTION RENTALS 04080107
AVE
OWNER'S NAME: PERMIT ISSUE DATE
MAN (714ANTC 1255 T41dIPH AVE
NE: SANITARY NMI.NO.
I� Llccnsc
HITECT/Eb1GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATIONI M.byafOrm the,1 am liecnsed under provisions of Chapmr 9(commencing Job Description
Section]0f111)ofDivision SofNC Businewand Professions Code,and my license is
ll foie and effect.
Clau Lk.g TEMP POWER POLE
��
M Date ContractorDECLARATION
ARCHITECTS DECLARATION
Y 1 unticnunJ my plena shall be used as public mrnrtls
7 U
Licensed Professional
ZO3 Met lam exempt( an CLARATION _
O I berthy.(Sere Inti 11. ,Bumph from the Contractors e:Any c Lew for the
ZOO which
regrecon.(Section](131.5,Business and improve,
de ore Code:Any city or county
$ which rtqusuv a Permit o construct,alar,improve,demolish,or repair any untrecm
Fzy hat he
Sensed pntrurn to
he ted visions of for Commumi'micensfile.e Law(Chapter
< thetW is licensed Putwanun Nc provisions of the Commuter's License law(Chepur9 Sq.Ft. Floor Area Valuatio
MZF0 (eammenring with Scctlon]000)nf DivisionJof the Businev and Fmfculons GldC)er
$
that be u exempt Merriman and the haste for don alleged exemption.Any violation of .A y f.faf,.. {��
Semon]0]L5 by any applicant for a permit wbjeau cin:applicant m a civil penally of .3 9`�J 3 V`�3'I O O Occupancy Type
not mom than five hundred dollars($3011). -
❑t.an owner ofthe property,or my employees with wages hat their sole compensation,
will do de work,and use,structure is notintended oronered formic(See.)014,Businw Required Inspections
and proposalCode:The Durnmemrs Lt.Law does out apply to sn owner of q p
property who holds orimprow thereon,and whodoessuch work himselfor irmugh his
own employees,provided Nat soh tmprovemenu tie noon girded oro@red forWe.IL
however.the building or improvement is mid within one you of completion.the owner.
bulkier will have die burden of proving that be did wt Wild or improve for purpose of O\
of
1 u owner of the property,am exclusively contracting with licensed contractors to
ns n d project(sec o an Businw and Pm(esons Cotler)The ConuecmYs nd
ce law docs not apply a is own.of prefer(}who Wilds a improves Norton.and
who mnuacu fonuch projects with...nuactor(0lianxd purwam m six Convac oh
Lkenx law.
❑lam rSee ,BAP th' on
Owner Date
U
*0'RK C SATION DECLARATION///
Ihembydilrmunder n tyofperjuryoncof Ne f0
5=1111"'eclanua
I halm and will maintain erdricaWof Comentmmlf-insumfa WorkesCompcn.
Sadon,as provided for by Section 37W of the Labor Code,per Me performance of the
work for which this permit is issued.
El 1 hav,and will maintain Worker's Compensation Insurance,ss required by Section
3700.f be IaWr Cade,for Ne performance of the wort for which this Permit is issued.
My Workers Compensation Imummce carver and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mcissection heed her be completed lithe hermit is Roche hundred ckdau(SIM)
or kst)
1 certify Net in the performance of Ne work for which this permit is issued,I shall not
employ any peourn in any manner m as to become subject to the Womers'Compensation
Laws of California.Dox
Applicanl
NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should
become subject or Ne Worker's Compensation provisions of the labor Code,you mull
.,z forthwith comply with such provisions or this permit shall he deemed revoked.
.Zi .~ CONSTRUCTION LENDING AGENCY
Nu
'ra I hereby affirm that there ill comwction heeding agency for Ne Performance of
C> the work fa whim this pamsil Is issued(Sec.3097,Ci,C.)
W Q Lentos Name
z Lamers Address
U0 I certify Nu 1 have read this application and state that Ne above infam asim is
IL,Hcorrect.I agree in comply with all city and countyMMMMCxs and state laws muting to
DU building construction,and hereby authorize representatives of this city to enter upon Ne
r a aWve-memtaned property for inspection purposes.
(we)agree or Save,indemnify and keep IMMCIM the City of C9Perlmo against I
.F.,res liabilities,judgmenu,costs and expenses which may In any way accrue against said City /
U z in consequence oft a Showing of this Permit.
APPLICANT UN ERSTANDS D WILL COMPLY WITH A L NO -P01 Issued by: Date
So IONS.
Re-roofs
Sig ort o(ApP on m x
HAZA 0 MATERIALS DISCLOS E Type Of Roof
Will the applicant are huh ing occupant umre or hentllehuallous materiel
u defmcd by the Cuputin Mutt I Code.Chapter 9.11,and Ne Hcaldh and Safety
ax.Se 10n z3s3xal? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Y=cdf
Will the applicant orrcupant usecquipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haramous air conumimy Ne Bay Arta Air Quality Management all new materials for inspection.
inrict?
❑Yes
I have mW deh.ndousmaterialsmluiremenu under Chaperd.95 ofd,Caliper.
hisHcaIM&SafetyCah.Sections 25505. 33and 235X.1 understand Nuiftnc Wilding
Jo.hrot currently ha a tenant,Nat it u rtspomibility x notify Occup of the
requirementsesnot whicA be met priuancc.17.CcniRcamu
/ Signature of Applicant Date
own Braame xeJ antAll roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: r � PERMIT# O , r 6q07
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete 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
Iv b
er/C ntractor Signature Dae
r,
CITY OF CUPERTINO
TEMP POWERCITY OF
'1 f
$CUPERTINO PERMIT APPLICATION FORM
APN# C- 33 D 34� Date: i3 O
Building Address: Q7
Owner's Name: , J7t7 Phone #:
Contractor: / L Q Phone: License#:
Q� <
Contact: n / O Phone: �L y Cupertino Business License#:
/' L �fQ
Building Permit Info:
Elect ❑
Job Description:
Residential ❑ Commercial ❑
Cost of Project: JT�
abI Fee ID Fee Description Fee Grou
BTEMP Temporary Power ELECTRICAL
PERMITFEE Elect. Permit Issuance ELECTRICAL
USLIC Business License BUILDING
z6 6