04070111 7777777
CITY OF CUPERTINO ''�" - °' o
BUILDING DIVISION PERMIT Cm 1'�YtA OR ZA1IaORMA.''�TO ;.
BUILDING ADDRESS. PERMIT NO04070111
OWNER'S NAME: PERMIT ISSUE DATE
FARIDEH MISAMI /20,12101-
E: SANITARY 0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGO ELECTO PLUMB MECHO
u00 LICENSED CONTRACTOR'S DECLARATION
U 1 hereby affirm Net 1 am licensed under provisions or Chapter 9(commencing Job Description
with Section Ill o'Division 3 of Ne Business and Professions Code,and my license is
in fell pace and affect. TEMP POWER POLE �
qZ Wccnx Clens Lic.11 `
tip Dam.Consumer aVaoa`
,eqq ARCHITECT'S DECLARATION
y 2 a I understand my plans shall be used as public records
u.0
3u.01 Licensed Pmfusionel
OWNER-BUILDER DECLARATION
CaroION
I hereby affirm on 1 am exempt sfreen
an Ne Cssion C t e:Any c Law county the
F.p O which
tcason.($center 7(I31d,Business and Professions Code:Any oily m county
$ which myus u a Pmmit to lrMe gime improve,h Permit t are.,.It structstatement
Fly Meths rnn
its issuance.e,alm mitoithe prevision or forsucthe Contractors
kenssigned stammtnl
sx< (mumor in,wiitpurauantmtheofDivisionlNeContractor'sLiccfaLaw mitmChapter ode)9 Sq.FL Floor Area Valuation
�m (comas Is exg with Breim.romand the Division r of Meal aged euand on.Any vi Cede)or
$
that he h exempt therefrom and the buts far Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penally of 3-11312 iBell 0 Occupancy Type
not marc than five hundred delta.($500). -
❑Loa Me work.
the pestruchure mmycmplayw with wagesns is(Sec.cW,Business
will Pr Ncwow endo: he Critical
licall Livensctil Law offered
formic 70 Ca,Business Required Inspections
prod property
whiobu Code:The Ce themor'e License Law docs not apply lf an owner of q p
property who builtlsmimpraws Improvements
are
crselfor through his
own¢ Iaycu,pmv]ded pr such Iimid wihin n.year tdM oroOcrctl for sets.If,
onsml
how a Ne building Orden of pment is mid within ane year of completion,Nepose at
tout
or
will have the burden of proving Net be did not build or improv for purpose of
Ifo owner of the property,am exclusively contracting with licensed contractors to
nswm Ne pmKct(Sec.7044,Business and Profusions Cade:)The Contractor's Li.
ce farm doeanat apply in an owner of property who Wilds or improves Meson,and
who,.nets for such projects with a eoneectal licensed pursuant to Ne Conmmar's
Lkenx law. -
❑Iwexempt under Sec. B&PC ,this tion
weer Da e
WOR C 'M ATION DECLARATIOf{,
I he
aliiw under Penalty of perjury ore of Ne following it. rens:
War and will maintain¢Certlficam of Consent to ulf-iname far Worker's Compere -
sestion,u provided for by Section 3700 of the Labor Code,for the Performance of the
work for which this permit is West
❑1 haw and will maintain Worker's Compensation Insurance,as required by Section
7'100 of the labor Code,for Ne limformanre of the work for which this pewit is issaed.
My Workers Compensation Inxmnce center and Policy number am:
Cenitr. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thb acmion neednmbemerro edifIbe pewit is farane hundred dollars(310() .
or Ices.)
I certify that in Ne performance of the work for which this permit is issued,l shall not
employ any person in any munnerx as in become subject to the WorkerCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Receptior.you should
become subject to Ne Worker's Compensation provisions of Ne labor Code.you must
.7. O out comply with such provisions or Nis Permit shall be discover!revoked.
IV) CONSTRUCTION LENDING AGENCY
4 I hereby affirm Nes there is a commuction lending agency for Ne performance of
CL the work for which this pewit is issued(Sec.3097,Civ.C.)
WM Q Lender's Name
=z Londerr'sAddress
U Q I certify that 1 have reed this application and sum Net the above information is
LU F coma.I agree x comply with all city and county ordinances and sum laws relating to
Q V building consmmon,and hereby authode representatives of Nis city to enter open the
[A above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless Me City of Cupertino against /yv
roil liabilidea,Jadgm seeedexpensu which may in anyway accme against mid City Xate7
z in conseyuenc of Ne ranting of(Mai Pewit.UND RSA DS AND WILL COMPLY WITH L NON-POINT Issued by:
SOURCE GU TIONS. /
Re-roofs
Si urco mr Date
US MATERIALS DISCLOSURE Type of Roof \\
Will Ne app]c nwrfmura uildin6 accupanlsmrc or hand].Waardous nual l
u ile0ncd by the Cupertino Mu opal Cotle,Chopmr 9.12,and Ne Health and Safety
Code,nutlet zsmz(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applies or foto wilding accupam sex equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
k hmardaus air conumul defined by Ne Bay Arca Air Quality Management all new materials for inspection.
7d-=notmxmmIy
inm?
Yea
I have mad Neh smamnala rcyuirementsundcr Ch.,ko 5oftheCalifor-
HeeWg:Safmyc ,Seco rte 25505,2s5I3 and 25534.1unomemnd Netif Nc Wilding
we ten ,Nm u nvf marooneibilisy w odly the aruPent ofNc
uire. whi seat etpdomin4nonceofI 'r of upanc Signature of Applicant Date
own err station m All roof coverings to be Class "B"or better
CITY OF CUPERTINO
zan TEMP POWER o �4
�UPERTINO PERMIT APPLICATION FORM
APN# 3Fj` OlO Date:
Building Address:
Owner's Name: Phone#: I/or— 3,z"y7rO
r �
Contractor: Phone��o: License#: 3 L
. crr s ✓ -- 60�� �" �9S
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description: ^
Residential ommercial ❑
Cost of Project:
&-.)
.
A/-t,.,-,n
Fee ID Fee Description Fee Group
MP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
7
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