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CITY OF CUPERTINO
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DIVISION PERMIT
CONTRAC°"TOR INFORMA ION
BUILDING
BUILDING ADDRESS:
045r, BYRNR AVE
PERMIT N0.05(]80049
OWNER'S NAME:
PERMIT ISSUE DATE
SESHARAO PATCHI
ONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG EIPCf PLUMB MECH
LICENSED CONTRAC OR'S DECLARATION
Job Description
I Wrcby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Sce ion vamp of Division 3 offt Boamessand Pmfcssiom Code, and my license is
in full fora and effect,
TEMP POWER POLE
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License Class X
Contractor
ARCHITECTS DECLARATION
I undcrsund my plans &hall W used as public mcofda
5O0Z _
7 �/^
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby I exempts Ne Canaa=laoa License Law for the
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affirm on II131.5,Businessand Profeasium Cmlc:Any city orcounty
followingmason. t. an
(`'l II \{ddb(((/fJ
which North impmw, pair structure
a pemst re enms
$800
da issu the applicant h pUMdL t fie ed
poor to da issuance. alsasm me the for suchperniuoftlnse,
Sq. Ft. Floor Area
u vYk
Valuation
Ucdnanmcm
thm licensed to 9
ndProflaw(sCode)
me Division of the Business andon.An Vi Code) or
(commencing with Section?
I that he u exempt dnrtlrom and d¢ baso for Ne alleged exemption. Any violation of
and the
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Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not marc than five hundred dollars ($500).
0I,mOwmcsofdxpmpcny,mmyemployewithwageswtheirfelero Mmtion,
Required Inspections
will do the wart and Nerwmurt is notin¢Mcd oroRerrA far rate(Sec.7614, Businw
and Professions Code: The Contractor's License Law dors Int apply n in owner of
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property who buildsur improves thereon, and whodoessuch work himself or through his
Own employers, provided that such improvements arc not intended Or offered forsale. If.
however, the holding., improvement is sold within one year of,muN.Om, Ne owmr-
builder. will have d. Wrden of proving that he did not Wild or improve for purpose of
sale.).
0 1, as owner of the property, am exclusively contracting with licensed contractors to
comtrun the project (Sec. 7014. Business and Pmfcssions Cotler) The Contractors Li-
cense law dors not apply to an Owner of property who Wilda or improw.s ftmon, and,
who contracts for such pnjects with a contracmr(s) licensed pursuant in the Contnetor's
License Law.
0 I am caempt under Sec. B At P C for Nis remora
Owner �Y —M" O Pn,t4c W Va Q Date 4 c�
- WORKER'S COMPENSATION DECLARATION
_
1 hereby affirm under Nulty of perjury arc of the following declarations:
I have and will maintain a Condiment, of Consent o self-insum for Worker'sCompcn-
ion, m provided for by Section 37W of the labor Code, for the performance of Ne
rt for which this permit is issmd. ,
1371W
1 have and will maintain Worker's Compcwlion Insurance, as ventured by Section
of the labor Code, for the performance ofthe work fm which this panto( is issuedy
Workers Compensation Insumna carrier and Policy number are:
rtier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Dtissectiou need not W eompmnd if the permit is fmonehundmd dollars (SI00)
or mss.)
1 certify that in the performance of the work for which this permil is issued, l shall not
employ any person in any mannerip as, coCsmcSbjecuOIM WorA Is'COmN.U.1lon
Laws of California. Dan X S -
Applicant Gro CY.nK�n�"'n41�
NOTICE TO APPLICANT: If. after making this Cenifmate o Emharuf n, you should
become subject ro the Workers Compcnsetion provisions of Oc labor Code, you must
forthwith comply with such provisions or this permit shallM dccmcd revoked.
CONSTRUCTION LENDING AGENCY
1 hereby o1Brm that there is agency for the Performance of
sed(Seeconstructionlending
' the work for which this permit is issued (See 3M. Cm C.)
Lender's Name
,
l.cndcr's Address
1 I cen?fy that 1 have read this application and sate Nat the above informuiun is
correct. 1 agree m comply with all city and county oNinanas and sum laws relating n
building convection, and hereby authorise mpaacroadws of this city to enter upon the
ahow-mcnduned property for inspection pur was.
(We) agree t0 Sia. lndammdy and keep harculeal the City Of Cupertino against
j Liabilities judgments. costs and expense which may in any way accrue against said City
in caruequenec of the granting of Nis parrot.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT
Issued by: Date Q
SOURCE RE�GULATION�
x �OSr I`
Re-roofs
Type of Roof
t SignaweofApplimmUContm<mr
HAZARDOUS MATERIALS DISCLOSURE
W0l tha applicant Or future Wilding Occupant store or Nmtle 6vallous material
as defined by tW Cupertino Municipal Cade. Chapter 9.12, and the Health and Safety
sere. Sc ed on zss3z(a)7
Dye
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
Win the applicant or future building occupant use equipment art dwmea which
it hamodous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
isuict?
O Yes
1 have mad the hasaedousmandals mquimments under Chaper6.95 of the Califor-
niaHcalth&Safely CWd.Scedons25N)5.23533.d2553C.1unars N.iOW Wilding
Jots not a mcntly haw a tenant Oak is my mspomibility In nosily the Occupant more
rcquirdmcn. which v Wmetpdormissuamcofa Cadfianofacupmcy.
Signature of Applicant Date
Sa�4.4 �• Ns rj-o7
All roof coverings to be Class "B" or better
Ownor or aumna.<dagem Dan
t
rM;r
CITY OF
UPERTINO
Buil
JOB ADDRESS:
10W S5 R,NRtoNV t'
OWNER'S NAME:
GENERAL CONTRACTOR t^
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
nt
5-8-;�2—
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:.
0.
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
-,Q o EkCLej st
Owner/ Contractor Signature
oS -OS- 0 -.S: -
Date
(40 r It
CUPEkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
APN # X57
Date: Oa- p5 -OS
Building Address: 104-55 6 /RNF AUE• CEJ PERTI NO GA, 950(4
Owner'sName:S�SNARRO Rrc+IIPAt.A
I�
Phone #:
405-832- 24-4-0
Contractor: g
License #:
Contact:
Cupertino Business License #:
Building Permit Info: ' S4alli T�rrt an �owev
Palsz
Elect 15 -
Job Description: NeW t-Wo-S-iOYA �10trn2
Residential.®- Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID
Fee Descrintion
Fee Grout)
BTEMP
Temporary Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING