06020066 (2) / CITY OF CUPERTINO
BUILDING olvtstoN PERMIT , CONU X bR IJOR'MAT- JON an
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BUILDINGADDR PERMITNO.06020066
10731 CARVER
OWNER'S NAME: PERMITLgUEDATE
ESMAEIL NEMATI
SANITARY NO. CONTROL NO.
ARCHrMCT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
op LICENSED CONTRACTOR'S DECLARATION Job DCSC(1 IIOT
1 herby Mm that 1 am licensed under provision of Chapter 9(commencing P
with Section 701)8)ofDNi ion 3 of the Buunmt and Profession Code.and my licence Ire
in mu forceandercen TEMPORARY POWER
�? LicenseClare Lic.0 .
Dau Contractor
ARCHITECTS DECLARATION
I understand my Phu shall he used as public records
te Licensed Professional
N OWNER-BUILDER DECLARATION <�
1 herby anion that I me exempt from the Contractors License Law rat the
o O following reason.(Section 70313,Business and Prefeuiuns Code:Any city or county \f w
$ which m luma a permit to cnuwm,atter,improve,demoluh,or mpalr any s=lur C
prior it)its issuance.also equiru the applicant for such permit to rile a signed statement
des M is licensed pursuant to the provisions of the Contractor's Liam Law(Chapter 9 Sq.Ft. Floor Area 'IV41dlitlyn
(eemnteneing with Sttuo,700 NDivision 3 of He Butiaesand Prouarions Code)or
$ that he b exempt therefrom and the bub for the)loft cumptiao.Any
violation of
Section 7031.5 by airy applicant for a permit subjeCU the applicant to a CIVIL penalty of F Occupancy Type
not mor than five hundred dollars($500).
0 I,u owner of the property,or my employes with well as their=to Compcnndon,
will do the work,and the structure is not ntended or offered for ssu(Sec.7044,Business Required Inspections
and Profession Code: Contractors The Coctors Liaisee Law does not apply to an—of q P
property who buildsor Important,Hereon,andwho doessuch wed,himselforU ental his
awn employees,provided Nal such Improvements are maintained aralfa m faun.if.
however,the building or improvement is said within as year of completion,the Owner-
builder will have tin burden of proving that he did not build or improve fa purpose of
Colo.).
❑I.at Owner of the property am taclusively contracting with licensed contraction es
contact the project(Set.7044.Business and Professions Cade:)The CmftoXm's Li-
ares,law des not apply to an r of propeny�who builds or Improves Hereon,and,
who contracts la ouch proje wish acontracter(8liamed purswmtotite Contrsewra
License Law.
1 em uempsynde .B k P C for Nb mason
wnsl
Data
0 S ON ECLARATION
I hereby a111.09k,penal y of perjury aro of the following dechma enc
❑1 have and will maintain sCenlfinte of Covent to self-inaum far Workers Compen.
satlon,as provided for by Section 3100 of the tabor Code,for He prrfarmana of the
wort fa which this permit is Issued.
❑1 haw and will maintain Workers Competuatian Insurance,as required by Section
3700 of the tabor Code.for the performance of the work for which this permit is load.
My Workers Compensation hourana carrier and Policy number ate:
Cartier. Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This aealotaW not becareplau iiftic Form,U Toone hundred dallan(SIOU)
or less.)
1 certify that In He performance he wads fa which His permit is issued.I shall not
employ any person in any tyv eo auto the Worsen'Compensation
ws
Laof Glifomla.Dell cons to -
Applinnt ) AC
NOTICE TO APPLI f,aria m his Coniacau of Exemption,you should
become subject to the Work Ompeuation provisions of the law Code,you mux
pfoMwhh comply with such provisions or thin permit mull be deemed mated.
7 v"' CONSTRUCTION LENDING AGENCY
r I bereby millse this ermdem b is a Ceuuatinn lendingagency far He performance of
L> He work ror which HU pit Wood(Sec.3097.Civ.C.)
QLenders Name
7 z Lender.Addeu
0 1 aNfy that 1 have read this application and mm that Oe above information is
L correct.I agree to comply with all City and county ordinances and some laws mlating to
Wilding constroction,and herby authorise representatives of this city to tour upon the
{47 show-mentioned pmpcny for inspection purpuet
y O, (We)agree to saw,indemnify and keep harmless the City of Cupertino alaiasm
In eonequence of the gond fthlpermit.
sen Iiabllifies,judgments,coats udexpenca which may In any way cc against said City
7 oa
F7 APPLICANT UNDERST SAN ILL COMPLY WITH ALL NON-POINT Issued by: Date
SORE tls ?_A19-0 G Re-roofs
Signature ofAepfftIIE1CNumW Duc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appllaot or future building aaupanistore or handle havArdous material
as dented by the Cupertino Municipal .Chapter 9.13,and the Health and Safety
_ Code,Section 35534()? All roofs shall be inspected prior to any roofing material being installed.
❑sea o
Will the applicant or future building occupant=equipmenl or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hauodo s aircontamimmus as dcOncd by the Bay Arca Air Quality Management all new materials for inspection.
Diurict?
❑W,
I haw mW the hvardwsmueriW requirements underChaput6.95of He Califor-
nbl-1.1 SatelyC 2550 33 and 73534.1 undcosond Chad ifthe building
Jes not c ntly a un Hu it b m Ihillty to notify tk Ocuput of He
Oyu c w ' mmtg9 t ase �u(ceaneenine,teorOcerpaney. nt Date Signature of Applicant All roof coverings to be Class"B"or better
Owner ora oris gc Duu
CITY OF CUPERTINO
�7 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37535003.00
DATE ISSUED. . . . . . . : 02/10/2006
RECEIPT #. . . . . . . . . : 33171
REFERENCE ID # . . . : 06020066
SITE ADDRESS . . . . . : 10731 CARVER DRIVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : ESMAEIL NEMATI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : ESMAEIL NEMATI
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
OEE 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 VISA
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
;101 Fax(408)777-3333
IRUPEI�TINO
Building Department
JOB ADDRESS: 073 1 CRiiVE'?, �R\VE PERMIT # oK
OWNER'S NAME: g—S W ^ PHONE # 4 S Z - �3
GENERAL CONTRACTOR - L FAX #
I am not using any subcontractors: M 9,,gd
a e 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
TEMP POWER
f�T
SCUPEINO PERMIT APPLICATION FORM
APN# 3 s b013 Date:
Building Address: I o 1 cu Q ,�T`N Q
Owner's Name: _ I �/ v Phone#:
_
Contractor: Phone:0 8 2 t _( 3 13 License#:
l
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description:
Residential K, Commercial ❑
Cost of Project: -� n
V
Qty. if
Applicable, Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING