05060203 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C"b 1NTRAC0Y2#INFORMATION ;
BUILDING ADDRESS: CRAFTSMENS GUILD INC PERMITN"0506 02 03
10580 SAN LEAMRO AV
OWNER'S NAME: PBRMITBSUBDATE
IM Nk MOHSEN AMINI 10566 S DE ANZA BLV 06/29/2005
NE: SANITARY NO. CONTROL NO.
(408) 366-1000
ARCHITECDENGINEEK: BUILDING PERMIT INFO
BLDG ELECT G� O PLUMB MECH
O O
o o LICENSED CONTRACTOR'S DECLARATION '
v1 1 hereby alarm Nat I am licensed under provisions of Chapter 9(commencing 0 o
r� with Sation]p10)rfDivuion3oftbe Busircasand Rofessions Code.aM myiicensc is
nfull forrowdal«t. TEMP POWER
ME LicensaGla.0 Lic.gl - 2005
Dam Contractor
fl
ARCHfIE understand DECLARATION
D i undcnJ my Piens l ho used
v records
public cordt I ®'
ala Licensed Pmfcasional
g OWNER-BUILDER DECLARATION I Bills
9 1 hereby am.that I am exempt from the Convectors License Law for timeWIMP
Q0 following mseon.(Section 7031.5,Business and Professions Code:My city or county
$ which requires a permit In construct.a mn improve,demolish.or repair any uncture 0
—z�^ prior to its iuuarom.also mgaims the applicant framch permit m ft...ignedst,mment
FF< thatbeulicensedpursoantmUeprovisiow.fMeCmummesLicenselaw(Chapter9 Sq.Ft. Floor Area Valuation
6$ mommenclag with Section 7000)of Division 3 of NC Business and ProfessionsCade)or
that been,exempt Nemfrmn and Ne basis for the alleged exemption.My violNon of
Section 7031.5 by my,applicant fora permit subject,the applicant to a civil penalty of
not mom than Ova hundmd dollars($500). Or Occupancy Type
❑1.asowner of Ne property,or my employes who wages a Mete sale eompensalm,
will do de wak add the.wcone is not intended aro(fered mrsale(Sm.]Ue1,Business Required Inspections
and Professions Cade:The Conuacmn U.Law dose not apply e an awes ns a( q P
Property who bulldsorimprovea themon.and who doessuchwank himselfor Uuough his
awnemployes,pmvidedthatsocbimprowmmaalenotintendedmoffr fwWe.if.
however,Ne Wilding or Improvement is mid within one year of completion.Ne owner.
builder will have Ne Wrden of proving Nat M did not Wild of Improve for purpose of
sakJ.
❑1,as awrcr of Me property,am exclualvely contracting with lianmd cenuxton to
convect Ne project(Sec.7044,Business and Profession Cede:)The Committers L6
mase,Law does not apply to an owner of property who Wilds or improves thenen,and
who contract,for such projects with a contractor(s)licensed pmmant In,the Comrmmrs
Lice.Law.
❑I un exempt under see. .B 4rP C fm this n,awn
owner MONS=—�I/ Date 44Q.Z
WORKERS COMPENSATION DECLARATION
1 hereby alder under penalty of perjury one of the following deeaaratirns:
I
hsw add.111 malnuin a Cenlliateaf Come;to elf-Warn,for WortersCompen-
7037.1W,I
n,as provided for by Secuan 3700 of the Lobar Code.for the Performance of the
rt for which this permit is issuel
1 have and will maintain Workers Compensation Insurance,as required by Section
of the LaWr Cade,far the pcuarmance of Me wort for which this permit is ieued.
Workers Compensadon Insurance eaukr and Policy number am:
rier. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complemJ if Ne permit Is foronc hundred dollan(SI00)
or lex)
I ar ify that in Ne performance of the work for which this permit is Issued.I mail not
employ say person In my m er o b ore yam to ft Workers'Compensation
Laws of California.Dam
Applicant L'J pffs
NOTICE O APPLICANT.If.after nu ing this Ceni cate of Eaemption.you mould
become subject to the Worker's Compensation provisions of Me U Wr Code,you muss
.J,'Z. fonhwgb comply with such Footmen or Nu permit shall be deemed revoked.
EM CONSBUCTION LENDING AGENCY -
(—m I hereby alarm that Nen,is a cmnaradnn lending agency for the performance of
lY7 the work fur which Ihta permit Is Issued(Sec.3097,Civ,C.)
ALendces Name ,
Z)z lender.Add.
V Q I certify that I law read this application and rete that the show,bar.W an is
r+ correct.1 agree to comply with all City and worry ordinances and some laws elating m
Q VC Wilding construction,and Manby mthodm rep.nadves of Nis city to enter upon Me
14 .hove-mendooed property fm Inspection purposes
G (We)agme to eve,indemnify and keep harmless the City of Cupertino gsinsr
C4 Iiabllita,judgmenls.casu and expense which may in anyway secrueagainst midCity
U In consequence of the granting of this permit
APPL NDERSTANOS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
5 ERE fa6,90NS.
Re-roofs
nuure ofA anVConlnclor D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant more rehandle hasandous m me ul
as defined by the Cupertino Mu p I Code,Chapter 9.13.and the Health and Safety
,dolkcede.Selves zss3z(a)7
Yes
YNo
All roofs shall be inspected prior to any roofing material being installed.
❑
will the appficmt or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
B hamadaus air conuminsnts as dcnmd by the Bay Amo Air Quality Management all new materials for inspection,
Irma.,
❑Yes
I have mad the harallous materials reyuimmems umki chapmr6.95 of the Cattle,.
nu Health&SsfetyCadc.Sxtiau 25505.25533 aw125534.1 understand thuiflhe building
Jashow a smart,that It 6 my responsibility to notify the occupant of Na.
rcqunmxmnt N;armit,uma rfacemnam of Occupancy, Signature of Applicant Dale
mer sirm ands est D
All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
pF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMTT#
OWNER'S NAME: PHO #
GENERAL CONTRACTOR FAX # --
L10
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
nip TEMP POWER v S?� 6 0
�CUPEkTINO PERMIT APPLICATION FORM
APN # p -0q
Date: 1, 1 n� og
Building Address: l 0E80 Sl 1 ) LFPJ�p P-0 NU
t F qF N
Owner's Name: I I ill Pho —3 G_ I 6 0
ontractor: P ne: Lice e #•
C
c -366 I n(3- sO-7
Contact: Ph ne: . Cupertino Business Lic nse#:
Building Permit Info:
Elect ❑
Job Description: "TQM j'Ote/)f-01 �Pn U,)a/2
Residential Commercial ❑
Cost of Project:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING