05090011 CITY OF CUPERTINO ' • tai r - ' -
BUILDING DIVISION PERMIT CONTRACTO,R`INFORMATION
,mA, x„e....,. wee �.w.�'a.,w ,A
0SuLOING ADDRESS: GARY STREAM CONST. INC. PERMIT NO 05090011
' OWNER'S NAME: PERMIT LSUB DATE
ONE: SANITARY NO. CONTROL NO.
(408) 247-2835
ARCHITECT/ENIGINE
247-
ARCHI'IECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
e
±s0o LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby sfRrm Nal I am licensed under provision of Chapter 9(commencing
with Section 1010)of Division 3 of the Business real Profession;Coe,,end mylittnsob
infullforeeandeffe v TEMP POWER POLE
?�2 License
AACHTIELTS DECLAATION
�i 1 undersunJ my plan shall he used as public records
Diu
Licensed Profeasinng SEP 7-r' 2005
OWNER-BUILDER DECLARATION
+� I hereby Affirm that 1 am exempt from the Contractor's License Law for the n[ ((77
j:00 following maven.(Section 7031.5,Business and Profession Calc:Any city or county iJ F` 'i
+�$ which requires a permit mo
nonuser, rs
r,altar.borrow.demolish,or repair any structure 1 ie, .
rZy polar.its iuuence,ales rtquima use applicant for such permit to Else a ingrvAsument V w
FFG
that he is licensed pursuant to the provision of the Contractor'sLicenuLaw(Chapter 9 Sq.Ft. Floor Area rcmrValbatid"ate
5S (commencing with Section 7000)of Division 3o the Business and Profeulam Code)or
u mfrom and the basis for the alleged exemption.My violatio
that he exempt tlen of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3%'?IIv 8Qffi6er 0 0 Occupancy Type
not mom than five hundred dolim(5500). p y •mJ p
❑Lu owmrofine property,mmyemploym with wagesu tleirwlecompenution,
will do thewark.and the ensure is notlmen led or offered f...Is(Sec.7044,Business
and Profession Cod.The Canmcmr's Lt.Law des tet only in an owner of Required Inspections
property who builds or improves thereon,and who don such work himself or through his
own employees.provided that such improvements art notlnunded aonered(rials,if.
however.the building or improvermord is mid within one year of completion,the owocr.
Wilder will hart the burden of proving that he did rot Wild or improve for purpaee of _
sale.).
❑I,u owner of the property an exclusively contracting with licensed wnuecuos in
consumer the project(Sec.7044,Business and Profession Code:)The Comoutim'a Li.
cenm Law does not apply in an owner of property who WIIN or improve thereon.and.
who contracts for such prgecu with a contrearm(O licensed pursuant in the Conractoh
License Law.
0 l am exempt under Sec .B Q P C for this recon
Owner Data
WORKERS COMPENSATION DECLARATION '
I hereby:'Zo under penalty of priory one of the following declaration:
mainta
I low end will in•CWwm
Oa(Consam m self-inure fa Weakens Canpen-
sat hor,u provided for by Section 3700 of the lata Code,for the performance of the
work for which this permit Is issued.
❑1 haw and will maintain Worker's Compensation Insurance.u m4uimd by Section „
3700 of Ne Labor Cale,for On performance of the work for which this permit is issued.
My Worke`e C9mrro�wtion uranw ler and Policy number am:
my w 1 J-J/zC 5f ;7 pdE y He.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section recd mothecomplemd lithe permit lsforone hundred dollars(3100) _
or lata)
I certify that in the performance of the work for which this Permit is issued.I shall not
employ anyperson in my mannerm u in Wwme subject to the Workeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL alter making this Certificate of Exemption,you should
become subject in the Worker,Compeasuon provision of the Isba Cade,you mug
,J O forthwith comply with such provision or this permit shall be decreed mated.
z^' CONSTRUCTION LENDING AGENCY
V;F I for which
lhel mart its mesSex.3 n lending Cm agency ler the perfu,mantt or
a. I a work les witch suis permit ts load(Sec.3097,Civ.CJ
Ig1 Q Lancer's Name
Q z Lender's Addreu
f,Q 1 cannily that I Mw mad this application god sum that the¢bow mr common I. '
QffrrcrosccL I age m agree with all city and county ordinances and sus,lave relating to
y. building construction,and hereby authain mpresenutives of this city to enter upon the
v[f7 above-mentioned property for inspection parpmes
. (We)agree to saw,indemnify and tent,hamdess the City of Cupenino against
it CAA liabllllles,judgments.eats a which may In my way accrre against aid City -
tJ in conmgoc me green n ! s fermlL
App
DER A ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULATIO
F Re-roofs �o�J•�
Signature o Ap ng I iso Dam
HA ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupanLiksts arhandle hazardous material
as dcOnd by the Cupertino Municipal Code,Chapter 9.11,and me Health and Safety
ak.seetianu53x(ar. yy// All roofs shall be inspected prior to any roofing material being installed.
❑Yes beNu
Will the applicant or future Wilding occupant we equipment or halms which If a roof is installed without first obtaining an inspection,I agree to remove
It halardnus air eon amounts u hrined by me Bay Area Air Quality Management all new materials for inspection.
aloin'?
❑Yes
Imv sadA
m:rielsmqulmmenuundcrCWpmr6.95ofmcCaliror-
tdaHw A, cry5505,253338 25534.lundcrsundthglfthe Wilding
dtesu ntlyet It u my rtspoalhility m noul'y ted occupant of m.
require yhicorinissuanceofaCertificateor, cupmCy.� Signature of Applicant Date
Owne,tar tl lGGouts All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
d Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT#
G6A1 j e AjL)r,1 OS090011
OWNER'S NAME: PHONE # 4/ 'r-Z4/7--ZS3
GENERAL CONTRACTM- FAX #
I am not using any subcontractors:
Si afore Date
Please check applicable subcontractors and corr fete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
low Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
T
er ontractor Signature Date
b 5D9 061 I
CITY OF CUPERTINO
TEMP POWER
UPEkTINO PERMIT APPLICATION FORM
APN # Date:
3�- ab-ww
Building Address:
/02 L-e iL E21 (JA
Owner's Name: Phone #:
KIC l
Contractor: / Phone: License#:
(� 2 �/�- 2l7_ zr3 39 d
Contact: Phone: Cupertino Business License #:
2 Gi -6 -sz8
Building Permit Info:
Elect
Job Description:
Residential Commercial ❑
Cost of Project:
/00 .60
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING