03080105 r CITYOFCUPERTINO x
BUILDING DIVISION PERMIT CRAII
ONTRACT(INFORMATION
Bu1LDINGADDRESS: ADAM ASKARI PEa'B"903080105
OW NER'S NAME: FERMM L95UE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MPRH
ico LICENSED CONTRACTOR'S DECLARATION JbDri tion
1H I hereby alarm that 1 am licensoDescription
ed under provisions of Chapter 9(commencing
with Section]0O)of Division]ofthe Budnm"Profeuit)MCa .a mylicmveis
v� in full force and effect.
)LIZ— Litems Clues Lic.g TEMP POWER POLE
i—O Dam W a Comncmr
ATION
q ARCHITECTS DECLAR
2 a I understand my plansshall used public ATION
16D
Licensed Pmfcscinnel p+/
1s S Oat I am exempt
from
DECLARATION
2O O I hereby affmm on 11. exempt from Jin Contractor's Co License Law for IW
O following mason.Permit
t ]onstr Business and improve.
de o demolish,
Code:Anyrepair
ay of county
5$ which itsad requires v permit re construct,alcor,improve,demolish,nr e a sig any suuctum
Z<
print in itsncesecc,rz .t 1.Me
dmvisiappon of forMe such Cmdpcnniuoice asignedsummcm
(hot he commesdimmed pursuant to N)of Diviansof Ne Con(rancie,and Proflsw(Chapter ode)or Sq.Ft.Floor Area Valuation
27,,x❑$ (cat he
(commencingwithScctionIDW)nl Division?of the
Ogd...apton.An oath)or
Nel he b exempt B¢rtfmm and Ne buts for the alleged caemp0on.Any violation of 34214085 . 00
Section 7071.5 by any applicant for a permit subjects the upplicML to a civil penalty of APN Number Occupancy Type
not more Nan Eve hundred dollars(5500).
❑I.u owner of the property.or my employees with wages star their able compensation.
will do Ne work,and Ne sanctum is not intended or offered for sale(Sec.]044,Business 103 — UPERRe UIIed InseeeCIIOnS
and Profeselosu Code:The Convector's License Law does not apply to an owner of 3 0 4 - ROUGH ELQuCTR I cAL
properly who hui Ida c r improves thereon.and who does such work hinuel f or through his
own employees,provided d at such improvements are not tnunded oroRered far sale.If,
however,Ne building or improvement is sold within one year of compiedon,Ne Owner.
builder will have the burden of proving that W did not Wild or improve for purpose of
sale.).
❑1,as owner of Ne property,am eeleively contracting with licensed contractors to
constmct Ne project(Sec.7044,Business and Pretensions Code:)The Coneractm's Lb
ecnse Law does not apply to an owner of property who Wilda or improve Morton,and.
who contracts for such projects with a convacmr(s)liceved punuam to de,ConlnctorY
cense Law.
1 ase exam under Sec I ,B&P C for this roman
Own A a CarK,nd, s 22 03
WORKER'S COMPENSATION DE ATION
I hereby efrum andel Penalty of perjury ave Of de following declanlious:
Ihave and will maimeine Condition of self-insure for WorkmYCompcn-
int n.,as provided for by Section 37W of the titer Code,for the performance of the
woh for which Nis permit is issued.
❑I have and will maintain Workces Compensation Insurance,as required by Section
7]00 of the Isom Code.for IW performance of the work for which this permit is banned.
My Worker's Compensation Insurance tamer and Policy num her am:
Curtis,. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
inns sectim need not uncompleted Ethe permit is for.ac hmodrtddnllars($10)
(ir leas.)
1 certify that in the pc annanns of Ne work for which Nis permh is issued,10111 not
employ any penoni io c esurItoMeWorkmx'fompensadon
Laws at California. -�
--
Applica
NOTIC APPLICANT:IL after making this Condition of Exemption.you should
once ject to the Worker's Compensation provisions of the Labor Code,you must
.J Q forthwith comply with such provisions or this permit hall be deemed revoked.
z "" CONSTRUCTION LENDING AGENCY
F+^ (hereby affirm that Nen is a convection lending agency for de performance of
a the work for which Ws permit is banded(Sec.3M.Civ.C.)
W� 0 Lender's Name
Z
U 1 linder' Add.
[�Q I ttnify that I have read this application and sou the the above information is
t6 F^ correct.I agree to comply with all city and county oNina vas and suer laws relating to
0U building construction,and hereby aithodre mprexnutivea of this city to enter upOn the
aMve-ince)agree
for impaction
mend anpurposes /h
(We)agme to cars,indemnity and keep harmless the y ac Of Cupenit s id City U[S/Vsl�
UTA in consequence
oromeoauand of this expenses which may inanyway action vgainstmdCity f'1�
U 7 A APPLICANT
of Nc granning of this D WILL
•^� APPLICANT UNDERSTANDS AND WILL CgMPLY WITH ALL NON-POINT Issued by: Dale
S R EREGU TIONS. S1 Q d(/'.yO
D C SRe-roofs
ignamm of ApplicanuConuacmr Dale
HAZARDOUS MATERIALS DISCLOSU Type of Roof
Will the applicant or future building Occupant store or handle h41zdous material
u leaned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
cam.Section zss5z(a)? All roofs shall be inspected prior to any roofing material being installed.
❑TeaN
Will the applicant or future Wilding occupant use equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
Il hazardous air conuminants as dcfr.d by the Bay Area Air Quality Management all new materials for inspection.
isvin? -
❑Yes INo
I have mud the haeNsws m_aurials requirements under Chapter 6.95 of the Califon
nia Health&SafetyCode.Section 25505,35577 ma135574.I undersand than iftha Wilding
does not curendy hove a named.Nm it is my responsibility to notify the occupant of the
m^ts pkhmost PryrwbanaMmbraC Rgrbra Signature of Applicant Date
Gann Nev ambarixed again l(a�� `fj^L2)� a1e All roof coverings to be Class "B" or better
r
CITY OF CUPERTINO �. v ( L S�
�` TEMP POWER
SCUPEkTINO PERMIT APPLICATION FORM
APN # '/ 0
3
Building Address: 'o L `1`
p 16 [
Owner's Name n �-a W As (C0.,K-( Phone#:
Contractor: S l 0."ZIPhone: q o r �7 3 I License #:
Contact: Phone: [ Cupertino Business License#:
Building Permit Info:
Elect
Job Description: . s
Residential ommer al ❑
Cost of Project:
Qty. if
ApplicFee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING