06020121 'C
ITY OF CUPERTINO
BUILDING DIVISION PERMIT W CONTRACTOR INFORMATIgN, .
BUILDINGADDRESS: JAHAN CONSTRUCTION PERMIT NO.0 6 0 2 0 12 1
10535 GASCOIGNE DR
OWNER'S NAME: PERMITISHUEDATE
JAHAN FARIDNIA 200 BURNETT AVE 02/21/2006
NE: SANITARY NO. CONTROL NO.
(408) 782-3102
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30o LICENSED CONTRACTORS DECLARATION Job-Description
ti 1 hereby affirm Net
et I am licensed under provision of Chapter 9(commencing
with Section 70(a))of Division 3 oftho Business and Professions Code.and my licensee '•
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Z Licenm Chis g Lie.«
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An—RCHil W use DELLA records
9 )rwGa(,
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CC 1 uMcrsunJ my plans atoll be T u public
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Licensed Pmfebrinnel
OW NEm exempt
DECLARATION r($$s�g fh!" �5y Its
aC Q 0 I hereby remo affirm that 11. exempt Tram the Contractors :Any C Law for the ,h B(s fg
1L'O D following moon.(Scotian](131.5,Business and Professions Cade:Any city or county 'u!j{j•J\,`'•pili
$ which requires a permit to emtswct,altar.improve,demolish.m repair my structure Ij $250
_Zt~" prior 0 its issunam.also requires the applicant for such permit to rile a signed mtamem
G thuheislicensedpursuanttotheprovisionsoftheCamrotorSLicenseLaw(Chapter9 Sq. Ft. Floor Area Valuation
(commencing with Section]00(1)of Division 3 of the Business and Prorchanns Code)or
3.. that he Is exempt Omrefnmt and the bails for the alleged exemption.My violas on of
Section 7031.5 by any applicant for a permit objects Ne applicant m a civil penalty of r Occupancy Type
not mom than frw hundred dollars($500).
❑I.ummrofthepropeny,mmyemploymwiNwguudxirmlewmpenudan,
wind.the work and theswctum is noammndeimoffmad tarsale(Sec.704,1.Business Required Inspections
and Profession.Code:The Contractor's Licenm Law dao of apply to an owner of q p
property who builds m improves thereon,end who does such work himself or through his
own employees.provided that such imptevemmu,am ant Intanded neo@rN for sales IL
hawewr,the building or improvement is old within arc year of completion.the owner
builder will haw Use burden of proving that he did not build or improve for purpose of
ark.).
❑1,as owner of the propcny,am exclusively mmorecting with licensed contractors to
construct the project(Sec.7044,Business and Pmfeuions Cade:)The Cantromr'a U.
cense law does not apply In,an awnea of Pont who builds or Improves themon,and.
who contracts for such projems with a rnntractor(s)licensed Pursuant he the Cantrsctofa
License Law.
❑1 atn exempt under Sec. .B&P C fm Nis moon
Owner Dose
WORKER'S COMPENSATION DECLARATION
1 hereby Mon under pensRy of perjury one of the following decimations:
1 have and will maintain a Certificate of Conmat mmlf-insum for Workcr'sComfort-
provided fm by Section 3700 of the labor Code.for the perfomanee of the
work for which this permit is imucL
❑1 have and will maintain Workefs Compensation Immance.as required by Section
3700of the Mbar Cade,for the performance of the wall for which this permit It issued.
My Worker's Compensation Insum¢e caoier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPnON FROM WOR ERS'
COMPENSATION INSURANCE
(This==.need oat be completed If de permit is far.hundred dollars($100)
Or less)
1 certify that In the Perfamunco of the work for which this permit Or issued.I toll not
employmypenaninmymannersoas bemmesubjmtto/M Workers Corr...into ,,
Laws of Calif n.Dam a"L�,r.�_(G2—
Apph 1 tqWp� ^t'^..,c O
NOTICE TO APS f�ll?a rmT r m,ki�diis CmRI� e�tion,you shwld
become object to the Workers Compensation pmvisions of the LaMar Code,you muss
.,O forthwith comply with such provisions or this permit shall be deemed revoked.
„zi "" CONSTRUCTION LENDING AGENCY
[..r► I hereby strum mat there iso commuctimt lending at fer de perfmmancc of
4i> the work for which this permit is abroad(Sm.3097.Cie C.) '
WM`n Lender's Name
D zLenders Address
U O I cenlTy that I Mw read this application and onto that the above information I.
W F correct.I agree to comply with all city and county ordinances and sum laws nlating to
DUbuilding construction,and hereby mwoim mpremntatiws of this city to enter upon the
W show-mentioned property for impecdon purposes
Ly,LL (We)agree to save,indemnify and keep ham lass the City of Cupertino against
k.I
In cwsequeoce of the granting of this permit.
M Iiablli0u,judgments,eosts and expenms which may in my way accrue against acid City
U F77
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date Z CtiG
SO RCEREGULATIONS. ` ,
gi y�py/�� ari�fy+rt R,2I Y In D Re-roofs
signets of lieanCaU ^instar 1— Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicant or fmure Wilding occupant slam or hendic hazardous material
as defined by the C."..Municipal Code.Charcot 9.12,and dw Health and Safety
.Se.d..23532m)? / All roofs shall be inspected prior to any roofing material being installed.
❑Yes V<6
Will me applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hmardous air cmuminants u dcrnnd by the Bay Am Air Quality Management all new materials for inspection.
District?
❑Yes two®
I have mad the Wero nuimatarialsrequirements underchapter6.95 ofthe Califs.
ria Hmlth&Safety Cade,Sections 25N15,25533 and 25534.1 understood thatiflhc building
does not currently haw a inane that it is my responsibility to sadly dao mcupam of the
�reyuireme hlehmmtW artoissumeeor.cndfrcataofoccupancy. Signature of Applicant Date
T w a .sa eZf 24gs�. All roof coverings to be Class"B"or better
Owner or wtho agent am
CITY OF CUPERTINO
Sim.- TEMP POWER
OF
$CUPERTINO PERMIT APPLICATION FORM
APN# Date:
3�S- ?8— o0A a, zl o
Building Address: n
105- aS6I' e— awk
Owner's Name: Phone#:
A NIA 782-31oZ
Contractor: Phone: .782_i1 o,Z License #: �20 ISO
Contact: Phone: Cupertino Business License#:
>•? 37 5-1l G 9
Building Permit Info:
Elect (�
Job Description: l e hN p orur
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPER ITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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