06070006 CITY OF CUPERTINO ^
BUILDING V VISION PERMIT �CUNCRACTnR'�IPTI<'OA,TIA1 '�'
r. '4`s• i4�r 9 .. TnGIbyF�'^... . ...e','AuE
BUILDING ADDRESS: NATIONAL CONSTRUCTION REN eISHr N006070006
10612 FLORA VISTA AV
OWNER'S NAME:
PERMIT rmmDATE
RICK BLESZYNSKI 1355 FILIPE AVE 07/03/2006
NE: SANITARY NO. CONTROL NO.
(818) 221-6057
ARCHITECT/ENGINEER; BUILDING PERMIT INFO
.BO EO PLO MEOCN
;oo LICENSED CONTRACTOR'S DECLARATION Job Description
�n F I hmcCy slims do,1 we licensed under provisions of Chapter 9(commencing
with Section 70M)of Division 3 of the Businw and Profession Code.and my licene is
in fail two And effea INSTALL TEMPORARY POWER POLE
License Class Lk.A
+ Dale Contractor
ARCHITECT'S DECLARATION
f 1 undemand mal plans shall he used As public records
J U
eta. Licensed Pmfcuienal
aN
OWNER-BUILDER DECLARATION
coo hereby alt m that 11. tempt from AB Cental Co e:MY C Lew(or my
5 p o following tures;. pantie t 713 1.5,Business and P e.der ns Code:Anal City Of county
$ witch rmussu a permit re lain th t alter,improm,h cOUbA,ar repair any Ymetum $400
i y prior u its issuance.p alsoreclaimto res the applicmt for sucContractor's
Lima LAW(Chapter
< that he(commencingwdpSambon Otho proviviemofthe the Business
nicenalaw(Chamer9 Sq.Ft. Floor Area Valuation
tham he
(commencingwishSecuon7000)the
Division of ft alleged
essand
ProfessionsMCMe)or
deet io b campy Uemfrom and dte bub for Ibe Weedppleatexemption.Any vlulNun of
Section 7031.5 by airy apPUcant for a permit subjects the applkanl an a tlHl penalty of Occupancy Type
ns,mom thRu Rw hundred dollars(25(10).
0 I,As owner of the property or my employees with wages As their Rule campensaUan.
will do the werk,and the arumurt b not intended or offered for We(Sec.IDN.Busixss Required Inspections
Rud Professions Cada:The Conit,elore Licawea,Law does not appy 0 an owner of q P
propeny who builds m improv trterm a.and wh a dons such wmk bine it ar through his
Own employees,provided thalaeh improvemmu are mtinlraded aro@red tarsals,If.
hooves,Ne building m improvement is sold within aIle year ofcmnpledon.the owner- -
build.coif have We burden of proving that An did not build or improve,for purpose of .
sok.).
0 1,As awuer of the propenY•Ann eschoively contracting with licensed mnaaman In
eouultet Ute project(Sec.7044.Business and Proreasians Code)The Contractors U.
cense law doer ARL OR a an owner of property who builds or improves thereon,and,
who contacts for Ff Projects with a can uac Ns)licanlad"MARI a the Continence, /
License Law.
❑lam m acrid es, .B&PCfm Nis tewq
Owner /!
WORKER'S COM SATION DECLARATION
1 he by of um under penalty of perjury Rae of the following daclaMou:
1 have and will maintain aCRMIRAte of Consent m self-Imam far Workers Compen- /
satian•u provided rue by Seetien 3700 of the Lab.Code.far tie perfasse.Of ted (10
work for which this permit b issued.
0 1 have and will maintain Workers Compensation Insunme,u required by Section
3700 of the Labor Code,fm the performance of the work for which thin permit Is,Issued.
My Workers Compensation Insurartee carrier and Policy number me:
Carrier. Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(nissmdmineede hembro le def Ne pennitla fa rte hundmddollan($100)
or lou)
1 mustily that in the pm rma of work far whic permit is imed.I Owl not
meIe anypc in Y r uk su mtk WorlmsfCompensNem
Lawn of Glilom ate
Applicant
NOTICE TO C, C .If aMr 1-1.11bnificate of an,you should
becmne abject m Woher's Compensation previsions of tie Labor Code,you mea
.J Zforthwith comply with rah provbku Or this Permit Nall be deemd.
ed revoke
O
z ti CONSTRUCTION LENDING AGENCY
[-r IherehYafrmmthat Nem Is.construction lending agency for to performsnm of
a > Ute work for which this permit Is issuer(See.3157.Civ.C)
W Lenders Name
z Lmn esmdrass .
U Q I certify that 1 have read this application arW sate that the sham information is
Ty F comm.I agree to comply with all city and county ordinances and sack lava elating 10
O U building construction,and hereby autherim Representatives of this city to enter upon the
0. above-mentioned property for inaNclion purposes.
(We)agree W ave,indemnify Rod keep harmless the City of Cupertino against
tih liabiI* judger U.cosu and Gpa, which may..any wyacrne against aid City
to can
V SOURSCANT R 1.
ER "ANDS thtsD WI OMPLY`WITH ALU.NON-POINT Issued by: DateS.
Re-roofs
Signature rAW.mAALC.ArM41 ask
HAZARDOUS ATFRIALSDISCLOSURE S Dk T*of Roof
Will dte applicant At future building amvPantstort At handle hazardous material
OR defined by the Cupertino Municipal Code.Chapter 9.12.and the HGIth and Safety
Code•Scolon 25132(a)? All roofs shall be inspected prior to any roofing material being installed.
Oyes Ne
41 0111 the applicant m future building Occupant tic equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaa dWs air m umminanb u dcrmcd by the Bay Acta Air Quality Managemem all new materials for inspection.
District?
Cl Yes Nu
the real aWeardaumu.lab gqmqq"qppIscmcrosubakCMpter A.95efdte Cali(or
nb Hwlth�S yC de,Seeuma25505,)3uul ZSSN.lumarmind I'mcbuilding
d net ntly he e•tenene dot it' y respomlbililY lo fury tic omup rt or de
req n win i esti q pd nrn,nmmnracmdk.teora gn'y. - 6 Signature of Applicant Date
o
Own ar horvedagen DRIB All roof coverings to be Class "B"or better
CITY OF CUPERTINO
!m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32608037 .00
DATE ISSUED. . . . . . . : 07/03/2006
RECEIPT # . . . . . . . . . : 35098
REFERENCE ID # . . . :, 06070006
SITE ADDRESS . . . . . : 10612 FLORA VISTA AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : RICK BLESZYNSKI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : THOMAS LIU
CONTRACTOR . . . . . . . : NATIONAL CONSTRUCTION RENTALS LIC # 22537
COMPANY . . . . . . . . . . : NATIONAL CONSTRUCTION RENTALS
ADDRESS . . . . . . . . . . : 1355 FILIPE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95122
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 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT . : 100 . 47 0 . 00 100 . 47 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
OTHER 100 .47 MASTERCARD
TOTAL RECEIPT 100 .47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
4kUPEkTINO
Building De artment
JOB ADDRESS: ' / PERMIT #
O R'S NAME. PHONE # -3
nib
GENERAL CONTRACTOR: `` 74ar 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 Ro k
Tile
- o - o
er/Contrac or ignature !ate Date
_ CI Ii CST IN® O(��CY.�CD
_TT EMP POWER
WUPERJINO PERMIT APPLICAT ON FORM
APN# Date: 2 oc) _
Building Address: ( 06 ( 2— F I o " ` ' I sTA }L
Owner's Name: p I G � �) e� z ' Woe —3 6(,- 060
Contractor: Wti _ P]aryl nec�� 1 I 1^� License #:
Contact: I Phone: 1, J,,,_1 t��.l-(���? Cupertino Business License#:
2Z 7
Building Permit Info: Te,,�
Elect
Job Description: O S Fs Rv`e —R , t � / C N e
1 i it ��l
Residential Commercial ❑
Cost of Project:,
• V
Qty. if
A2plicable Fee ID Fee Description Fee Grou
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING