05110137 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CoNTRACTR �TkORMATO3,,N ?
BUILDING ADDRESS: PERMIT N0.05110137
-10534 GASCOIGNE DR
OWNER'S NAME: PERMIT ISSUE DATE
KHOSROW KHAGHANI 11 /2-1 /2005
IFNE: SANITARY NO, CONTROL NO.
ARCHITECVENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
i o oLICENSED CONTRACTOR'S DECLARATION
C Job De$CT1pt100
c CaI hereby affirm that I am liaised under provisions of Chapterommc
9(cming
section 70)B)of Division 3.(the Bice.and Profession Code,W my license is
'may with infail force aaderfa,. TEMP POWER POLE
License Class Lic.0
=Fp Dale Contractor
a EARCHITECTS DECLARATION
f m-a I understand my Plans shall be used as public records
)yU
�o�' Licensed Pnmfessional
3 OWNER-BUILDER DECLARATION
1 hereby affirm Itsl I am exempt form the Chroniclers License Law for the
p 0 fh lhwing malar.(section TBJ LS.BaSlnetS and Plo(C6iam Code:My elfy or county
which requires a permit le cnnsuuct,alter,improve,dcenolish,or¢pagr
act..an,sctsm - $726
Yuipnor m its issuance.also mqut.thcapplieang farsoch penncm file.signed statement
that he alianaed purwanuh me provisions of the Chairman's Ucetase Law(chapu,9 Sq. Ft. Floor Area Valuation
YFe (chmmendng with Section?W()of Dwisi.n 3 of the Business and Protesst...Code).,
i that be is tempt therefrom and the huge fm the a leged crumpling.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant an a civil penalty of r Occupancy Type
not more Nan Eve hundred dollars(5500).
Q 1,as own••of the property or my esoployces with wages as Nair sole compcwdon,
will do the work..4 the someone is nal interred her offertd far sale(s«.7044,Budttess Required Inspections
and Pm(esslam Cade:The C.nuacme,Lt..Law dos rot apply m an owner of q P
propcny who Wilds.,improver tMcon,andwha dhcamchwork himself.,through he
own empl.yme,provided that such improvements ate nh(inmmod reoffered forsale-If.
however,the Wilding or improvement is said within arc year of eumpleuon,the ounce,
builder will have the burden of proving Nn M did not Wild or improve for Pon=of
salt.).
I,as asoma of the pmpeny,am exclusively eonseeling with learned mnauctors m`
amwct lite pmjev(sec.yo44,Ricain.and Norman.Code:)The Convamar's Li.
Genre=c
Law docs not app1Y m an owner of property who Wilds or improves thereon,and, \
who mnuacss far such pmjetts with a antrcmr(s)licensed pursuant m the Conuacmrs
Licnce elaw.
Qm
laexcrepgundm See .Rh PCforthit.
wn�r Data — —
W ER'S COMPENSATION DECLARATION
1 hereby alErre under pemlty a(perjuay on.of the following declaration:
1 him and will maintain a Certificate of Con ent w self-imum fw Workers Compcn-
svior.m provided for by section 3]00 of the labor Code.I.the peAormarcc of the
wart for which this permit is based.
0I have and will maintain Workers Compensation Imuran,as required by Section
B)of lite Isbor Cade,for the performanee.(the wont for which Nu permit is isgued. '
My Workers Compensation Insurance cagier and Policy number me:
Cagier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(Thu setting recd not W cmnptetcd if Ne permit Is foram hundred&Ji rs($100)
or est)
1 certify thus in the Performa..of the work far which this parent,u issued,I dull not
employ a a,person in my manor,W9 in Mcomewbjecl to the War"Compansation
Laws of Catilmnia.Dawe
Applicant
NOTICE TO APPLICANT:If.after makii4 this Ccntftcate of Exemption,you should
become subjm as the W.Ixcrl Compensation pmvisians of the labor Cotle you muss
.J Z forthwith comply with such provisions or Nu permit ahall W domed rewgked.
Z'O CONSTRUCTION LENDING AGENCY
[--t Ihcrebyalfirm dug dem iso ronsaucuan lendingagcmy(a,the per(onmanaf
C the wish for which this permit at caused(Sec.3097,Civ.C.)
a0 Lenders Namc ,
.7 z 1come,Address
V Q 1 certify that I have mad this application and sum then the aWve information is
ray correct.l agree to comply with.11 city and county o damusust and sum lawa relating m .
U Wilding construction,and hereby authomc representatives of this city m crater upon me
r 1 above-mentioned property far inspccdo,purposes
(We).gra to save,indemnify and keep harmless lie City of Cuperur o agaiml
Iiabilitia,judgment,cru and eapemu which may in any way acvac against said City
C)z APPL CANT UNDERSTANDSf ANDnnil-
WILLCO PLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
e-roofs ✓�•�i
SignatureafApplicanUC.nuacmr Data
HAZARDOUS MA ALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupentvom or handle harardom material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and sdcsy
.Settlor 25332(x)? All roofs shall be inspected prior to any roofing material being installed.
col Nn
Will the applicant or futum Wilding occupant tax equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazard..air co u as defined by the Bay Area Air Quality Management all new materials for inspection.
7Digric,'
QYm �No
1 have read the harardtaumamriau req.kanncnu underChamr6.95a(t1c Califor-
iaficalthkSdmyChM,Sceuanu 23505.25533 nd 25334.1 under",.n thssifthc Wilding
ocs not currently have a=ML Nat it c my responsibility m mufy the=gFum of thequirements which mutt be and armimuan oft Cemfilam.fOccupancy. Signature Qf Applicant Date
All roof coverings to be Class"B"or better
wner or aughorixcd agent Dam' '
Community Development
10300 Torre Avenue
y r- Cupertino CA 95014
Telephone(408) 777-3228
� CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
l 0S3 oS1t b1-3
OWNER'S NAME: kVva4vw� C\, p���y PHONE # qaV &S+— `$1
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
CITY OF CUPERTINO
S-of. TEMP POWER o S �/�l3
$CUPERTINO PERMIT APPLICATION FORM
APN # � 3 Date: � ` O
Building Address:
Owner's Name: S�W`C\�� Phone 9:
Contractor: , w, Phone: (\S -r K,T• License#: /
Contact: Phone: C Cupertino Business License #:
. ,Mc�'ck �a��kc�� 0. � —03��1
Building Permit Info:
Elect C�
Job Description: L,�jilc�Ll r� ?�'�� PC)C �l �G
Residential �-j Commercial ❑
Cost of Project: �Q 20
Qty. if
Ap licabl Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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