07110008 CITY OF CUPERTINO �a,�T an r
BUIL15ING DIVISION PER1Y11T �'CO ITRe1C'�Q�t Il\ � AT10 q<
BUILDING ADDRESS: PERMITNO.
10185 EMPIRE AVE NATIONAL CONSTRUCTION 07110008
ER.s NAME: PERMIT 155UE DATE
RICK BLESZYNSKI 15319 CHATSWORTH ST 11/01/2007
PHONE: SANITARY NO. CONTROL NO.
(818) 221-6057
ARCHITECT/ENGINEEK: BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
t� I� 0
O Q LICENSED CONTRACTOR'S DECLARATION IOb Description
U 1 Mreby affirm Net 1 ser Iicema d under provisions of Chapter 9(commencing p
widsaction 70(10)ofDivWon 3ofthe Buanessand Profesalons Codo.and mylicenAu is TEMP POWER POLE FOR BOTH HOUSES 10185/10215
O N in full to.and effort.
gig? License Class Lic.d EMPIRE
Dam Contractor
ARCHITECTS DECLARATION AVE.
I undcrsund my Pura shell he mind AS
public meet&
6
hLicenAud Professional
Mm3 OWNER-BUILDER DECLARATION
i 5? I hemhy alTirm that I am exempt from the Contractor's License Law far the
C 0 0 following mason.(Section 7031.5,Business and Professions Code:Any city or county
110! which requires a permit to conswc.alter.improve,demolish.or repair any swetum
i'n poor in ins issuance.also requires the applicant forsoch permit to file a signed summers
€o that he is licensed pursuant to the previsions of Ne Contractors License Law(Chapmr9 Sq.Ft. Floor AreaValuation
3 (commencing with Section 7000)of Division 3 of tie B usiusss and Professinna $Code)or 380
— that he is uempt Mtemfrom and the basis for ism alleged exemption.Any violation of
Section 7031.5 by any applicant for.permit abjecu the applicanLto a civil penalty of Number Occupancy
net mom than five hundred dollars(S50B1 32622029 Parc y Type
❑1,As owner of the property,ar my amployces with wages an their sole compensation,
will do the work,and destruetum ianot(mended or offered fonale(Sec.7014,Business
and Professions Code:The Contractor's License Law don not apply to an owner of Required Inspections
property who builds or im prow demon,and who does such work himxel f or through his
own employees,provided dust such imprewmenu am not intended aoffesed fmsele.If.
however,de Wilding or improvement Is Sold within one year of completion,the owner-
builder will have this burden of proving des he did net Mid or improve for purpose of
ssu.).
s mvner of de property.am exclusively contacting with Iicntaetl conmctora to
moon the Project(Sec.7000.Deal.=and Professions Cade:)The Contractor's Li.
came Law does not apply m an owner of Property who Wilda or improves demon,and
vein
la Cone such projects with w
a conemKO licensed pursmnt rode Commentri
w
❑1 e,^ t ,B&PC Nimy`t�n
er �-M—Naiac Dau 'AY•
WORKER'S COMPENSATION DECLARATIGN
1 hereby aabm under penalty of perjury arm of the following declarations:
❑Iheve and will meinuina Cerdfiesu ofConxenuo xlf-inanmfmWmker'aCamper-
sulon,u provided fa by Section 3700 of the Labra Code,for the performance of the
work for which this pnmit is iuued.
❑1 have and will maintain Werrker'S Compensation Insurance.u required by Section
3700 of the Labor Coda,For Me performance of the work for which this permit Is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier, Palley No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Auction need nos W completed if the permit is for one hundred dollars(SIW)
or less) �
I certify Mut i c peresmenc./f de gorIS ff which this permit u issued.I shall not
employ an eco )narryvnarlrcl2a(SbbecYdtc subject to de Warless Compensation
laws of Ca iia ar df IU 11
APPlicam 1 1
T
NOTICE O ICA! .IC a m
after mi riu CeniflUM of Exemption.you should
WCMM Subject m the Worker's Compensation provisions of due tabor Code,you most
.0 O forthwith comply with such pravisiou or MiS permit shall W domed mvmkad.
LZi y CONSfRUCI'ION LENDING AGENCY
E-a I hereby allifm deal dem is a construction lending agency for the performance of
ai 7 the work far which tide permit is issued(Sec.3097,Ci,C.)
WM LenMs's Name
Lender's Address
U O 1 cenify that 1 have reed this application and sum thu de above befmmNun is
LU F Carmel.I agree to comply with all city and county oNinances and stam laws misting to
0U building convection.rod hereby sutharia mprmenudw of this city in enter upon Me
W abuve-menudgm property for inspection s pugmAus
(We)agree to saw,had and kap Woman the City of Cupertino against
s.a rA liebllitresoudgmcnu.eosu and expenses which may in any myaarneegalnst said City
U,'Z iso quince of the dnnung of thin permit.
^' PPL ANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date Gt,�
S U q�I UL TIONS. I
W W (til ; IIf114 Re-roofs
Srg�w mmol AppliCm CO err t Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof �—
WIII the applicant or forum Wilding acupantuom arhendle incudes,material
derad by de CupeNna Municipal Code,Chapter 9.13.and the Health Lid Safety
Section zssuu)7
❑radyaAll roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan ins ection,I agree to remove
WIII Mm applicant in future building by the Bt sax equipment or devicag which P g
emitdem air contaminants u Mcfiatl by de Bay Area Air Quality Management all new materials for inspection.
District?
❑Ym
I have mad the Moratorium,mamriW requimmems under ChapW 6.95 of the Califor.
n! dthuifdc building
no rtPtn y have a morn,Mut h u my mapomiNiby m noul'y the oaupmi of Mu
M
c ichmum Wmet pdarlaissuance or&Cenlfimuarleparcty tlSignature of Applicant Date
Yl B
Owner of authariwd agent Dom All roof coverings to be Class"B"or better
-� CITY OF CUPERTINO
® TEMP POWER
40UPEkTINO PERMIT APPLICATION FORINT 6 )1106 Y
APN# 3a �a oa. 9 . v� Date:/0 -3 ' o2Da
Building Address: q,`�'i°.
J , �•V1,eJ P
Owner's Name: �p f�
Contractor: Phone: License #l: ���n� Gol1T
�, ��� Zd'o-Z Do 6871 ba
Contact: Phone: Cupertino Business-License
Building Permit Info: P�� �intQJL
Elect /�r`f'� " '\� `�vr' �OYR/Yy �(lG✓��L pd �>
Job Description: 0
Residential Commercial ❑
Cost of Project: •3�(
•
Qty. if
A licable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE . Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
•
• CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: christya
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32622029 . 00
DATE ISSUED. . . . . . . : 11/01/2007
RECEIPT #. . . . . . . . . : BS000003142
REFERENCE ID # . . 07110008
SITE ADDRESS . . . . . : 10185 EMPIRE AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER RICK BLESZYNSKI
ADDRESS 10185 EMPIRE AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1243
RECEIVED FROM . . . . : THOMAS LIU
CONTRACTOR . . . . . . . : NATIONAL CONSTRUCTION RENTALS LIC # 22537
COMPANY NATIONAL CONSTRUCTION RENTALS
ADDRESS 15319 CHATSWORTH ST
CITY/STATE/ZIP . . . : MISSION HILLS, CA 91345
• TELEPHONE . . . . . . . . : (818) 221-6057
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 40.79 0 . 00 40.79 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 102 . 89 0.00 102 . 89 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 102 . 89 MASTERCARD '
---------------
TOTAL RECEIPT 102 . 89
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
•
Community Development
10300 Torre Avenue
q4. . .
Cupertino CA 95014
Telephone(408)777-3228
TCITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS:`O PERMIT #
OWNER'S NAME: r2l-e 5: C. PHONE # aZ 80—Z 0-
-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
Owner/Contractor Signature Date