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aulLlnrlc urvlsloN PERMIT
RACTO
CIV R INF„ORMt1�'TIOIVJ„
BUILDING ADDRESS:
H MISAMI
PERMI `06040108
19411 CALLS DE BARCELONA
OWNER'S NAME:
PERMIT ISSUE DATE
FARIDEH MISAMI
04/20/2006
ONE:
SANITARY NO. CONTROL N0,
ARCHITECT/ENGINEER:
IN PO
L B MECH
LICENSED CONTRACTOR'S DECLARATION
1 thereby affirm NI am licensed under provisions of Chapter 9 (commencing
lob Description ,
��0at
n rest 1006
with Sat7000)ofDividan 3oftM Bupassand Profession, Code. and my licensee
In full rates and efrnL
INSTALL TEMPORARY POWER lih
License Clara Lk. Y
LI a
De¢
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a NIa =aO
murm
1 understand my plans ll) he� d
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby else that I am exempt from the Contractors License Law far the
following mason. (Section 703 1.5, Business and Professions Cale: My city at county
$792
, 9 2
which requites • permit to ennsuucL ante, improve, demdlsh, ter repdr any swcturt
prior at its issuance, alta requires the applicant for such peril to nic a signed statement
Sq. Ft. Floor Area
Valuation
Nat he u licensed pursuant m the provisions of the Contractor's License Law (Chapm9
(commencing with Section 7000) of Division 3 of dro Business and Profusions Code) or
that he is exempt dertfsom and the Audi for the alleged a romptim. Any violation of
AFN Mlfibbr
Occupancy type
Section 7031.7 by any applicant far a permit subjects the applicutl to a Civil penalty Of
not mart than five hundred dollars (SSW),
T, as owner of the property, or my employees with wage u theirmle compensation.
Required Inspections
q P
will da the Mark, and the prodtrre It not intended oranered formic (Sec. IOM, Business
an Of
Nd Pmrnpone Cade The Commences Licence Law n donot apply m owner
property wno Wilds orimproves thereon, and whitdao tachwoM1nWaenrarlhmugh his
awn employees, provided thatsuch improvements am ret intended oroaered forme IC
however, the building or improvement is sold within aro year of cemple0on. the "Act-
wnerbuilder
Wild,'will have the burden of proving that u did sot Wild or Improve for papose of
sale.).
❑ I. As owner of the Property, am exclusively contrasting with licensed m
construct the prefect (Sec. IOW, Businns and Professions Cade:) The Commences Li -
come Law does nal apply us an Owner of property who Wilda or ImproW NGRaa. and,
who concocts for such projects whit a conlracurds) licensed pursuant An the Com acme -
Litems, Law.
❑tun esemt es, ,B h P C for this recon
D
Owner Date
1P SATION 0 LARATION
I A mby affim under penalty of perjury one of to fallowing dnlammone
❑Inave aro will of Consabrsalt-ineuze me
forbyeCeNRae iWofkNact,of
adon, u provided far 31W of dm isnot Cade, for the perforenee of the
Ss
work for which Nis permit is issued.
mi issu
❑ 1 have and will maintain Workees Cernpensalion Imbrium, As required by Section
31W ofthe Lmer Code. fa Ne performance of Ne work farwhlch Nis permit i$WWW.
My Workers Compensation hamrsnce artier ad Policy number am:
Carder: Policy No.:
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
r
(This section need not be completed if de permit is force hundraddollan (SI00)
or lam.)
I certify that in be purfureraewart fa which this permit b issued. I mull no
employanypmmA in an r aambaome jaste a Co
Law, of Callfom A. D
Applicant
becomes TO APn L e este of on, you Nauta
r Cork you must
the wartm'o Compensation provisions of Nc Labor
become subject the
nced
' fonhwiNcomPlY with such pmvisiaaaNu Permit MplbedamW revoked,
y
CONSTRUCTION LENDING AGENCY
'
I hereby alar that there is • construction30 lending Agency for the Performance of
de Murk fur whim this Permit is lived (Sec. (Sl. Civ. C)
1 lenders Name
Lsndeh Addmas
i 1 unify Net I have rad Nb application and Cute that the stave information u
COMCL I agree m comply with all city and county ordinances and mu laws misting to
Wilding construction, and hereby authorize mpncsenmiws of Nis city m enter ON. the
for inspecdan
a1mve-mentioned InoNny purposes
(We) agree to sive, indemnify and kap harmless the City of Cupertino agairut
i liabilities. judgments, costs and expenses which may In my way mems, again. aid City
in comeganee of the granting of this perll.
' APPLICA ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date — 2- o— 6 G
y
50 E LATIONS.
O
—
Re -roofs
Type of Roof
Si e Data
HAZARDOUS oMATERIAISDISCLOSURE
Will the applicant or future Wilding aceupanl pore a handle havrdom mamdal
as defined by the Cupertino Municipal Code. Chapter 9.12. and live Health and Safety
Cade, Section 255324)1
All roofs shall be inspected prior to any roofing material being installed.
❑Yu ONo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant me equipment or devices wnich
emit haysrdna air contaminants u dc0ned by the Bay Area Air Quality Management
all new materials for inspection.
Dimicrl
❑Yes ❑No
I have read the Amoad. oras edala mmmarrom s undcrClupter 6.95 of the Califon.
nuHil &Safcty Cade Sen 25505,25533ar 25534.1uMcrsumdN ifde Wilding
does Trot tun out how a ¢nano Nn It u my responsibility to notify the occupant of the
require c hmust be met Prior toissumaogCertificate afocc ,a
Signature of Applicant Date
All roof coverings to be Class "B" or better
e DateU
•
•
L
Buil
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Dartment
JOB ADDRESS: PERMIT #
G(ctl� Cc��2 (3crcelGnq C�60Yoe/ Dd"--
OWNER'S NAME: r; C PHONE # e(,:q 7 _ 2 -
GENERAL
GENERAL CONTRACTOR: &A C o-e.lvw FAX #
I am not using any subcontractors: �b5 n'I I �� N✓ �c-�%LL
gnature Date
Please check applicable subcontractors and complete the following information:
ff,'��vner/ Contractor Signature
Q
Date
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
ff,'��vner/ Contractor Signature
Q
Date
4m 1 of 1
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN .......... 37504013.00
DATE ISSUED.......: 04/20/2006
RECEIPT 4.........: 34059
REFERENCE ID # ...: 06040108
OPERATOR: amyw
COPY # : 2
SITE ADDRESS .....: 19411 CALLE DE BARCELONA
SUBDIVISION ......:
CITY .............: CUPERTINO
IMPACT AREA ......
OWNER ............: FARIDEH MISAMI
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: FARIDEH MISAMI
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: FARIDEH MISAMI
ADDRESS .........::
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE ........:
•FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
----------------------- --------------------------------------------------
BTEMP FLAT RATE 1.00 62.10 0.00 62.10 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
TOTAL PERMIT : 100.47 0.00 100.47 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ -------- w
100.47 VISA
TOTAL RECEIPT 100.47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -------------------
-------------------------------------------- -------------------
103 UFER 304 ROUGH ELECTRICAL
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16CITY OF
CUPERTINO
CITY OF CUPERTINO
b(AVo8
TEMP .POWER
PERMIT APPLICATION FORM
APN # 515-D4
11-� _O,5
Temporary Power
ELECTRICAL
Date ^ 2-0, Q
Buill (ddress:
19 L
ELECTRICAL
C LO/✓
wne is ame:
R
BUILDING
Plh ne #:
Contractor: .4 Phone:
OIV 4L Covw r�c--1 ; U n
Contact: d Phone:
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License #:
eD (� 8--7 16 0
Cupertino Business License #:
BuildingPer/mit Info: i
Elect LAY
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Job Description:
Residential Commercial ❑
Cost of Project:
•
0
Qty. if
Applicable Fee ID
Fee Description
Fee Group
BTEMP
Temporary Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING