05110156 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT 1,CONTRACT RJNK RMATION'`
BUILDING ADDREss: NATIONAL CONSTRUCTION REN " "05110156
20931 GREENTRAF DR
OWNER'S NAME: PERRUT ISEOE GATE
ROHIT KAPUR 1355 F
NE:
SANITARY NO. CONTROL NO.
(818) 221-6057
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
i O O LICENSED CONTRACTOR'S DECLARATION IOb.D0sCrlpClOn
wC 1 hereby affirm Nal 1 am licensed under provimmas of Chapter 9(commencing
with Section 70W)OfDivision 3 aide Business and Professions Code.and my license is
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Come
T/Ob Contracwr
ARCHITECTS DECLARA+ION,
f e I understand my plans shall W used as public records
)yU
g y Licensed Professional
g OWNER-BUILDER DECLARATION
"tit p I hereby aRrm that I am exempt from the Contractor's License Law for the /
❑O following mason(Section 703 IS.Business and Profession Cade:Any city Or county
m 8. which¢quirts a permit to counteract.alter.improve,dceralish,or repair any structure S5 0 0
no.,units issumwC.ml o,quimt the applicant for such permit to file a signed awkmem
E=n NmhcisBcenodpunuantmlWpmvisiomofthcConlracwr'sLlccnclaw(Chapwr9 Sq.F[.Floor Area V lua[ion
exp (commencing with Section 7WO)o(Division J aftW Businrssand ProressinsnCoAc)ur
NR Nat he u exempt Bwrelrom and the basis for the alleged exemption.Any violation of _
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty,of 10ccdparicy,Type
not mom than five hundred dollars(55110).
C3 1,as owner of Ne property,or my employes with wages as their sole compematlon,
will du the work,and the sweturt is not intended or offered for sok(Sec.7014,Bm1ss
and Profession Code:The Contractors License Law does not apply to an Owner of Required Inspections
property who builds or improves thereon,and who does such work himsel f or through his
Own employes,provided Nat such improvements are not intended Or offered torsade.If.
however.Ne Wilding or improvement is sold within one year of completion.Ne owner-
Wildwe will have Ne burden of moving that he did not Wild Or improve far marpme of
sale.).
❑L as Owner Of the popery,ren exclusively contracting with licensed contractors to
construct Ne project(Sec.7044.Business and profession Code:)The Contruaer's Li-
ems law does not apply us an Owner of property who Wilds or imprevat Neuron,and
who contracts for such projects with a contractors)licensed pursuant w the Contractors
License taw.
1 am exempt under Sec .B&P C for this matron
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declantion:
1 have and will maintain a Cerdfica a of Consent On self-insure for WOrkcrsCommit-
sazion,as provided(m 00
by Section 3] 0f Me Lidice Code,for the Performance of Ne
work for which this Permit is issued.
I bon and will maintain Workers Compensation Insurance.as required by Section t
]O0 of Ne labor Code,for Ne per(Ormanee of Ne work for which this permit is issued.
My Workers Compensation Wurtan�ce carries and Policy number art: c
C.one r.7'�Lo.t,nn.P.e.. des+- Polley Nn.:,-rR2h UYr'1..720 I^ oy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nrm section need not W compicwd if the permit is fora.hundred dollars($100)
or loss)
1 cenlfv Nat in Ne Performance of Ne work for which this Permit is issued,l shall not
employ any person in any manner an as to become subject to the WOrkers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making Nis comriierve of Estuarine, a.should
become subject w Ne Workers Compensation provisions of Me labor Codas you mum
.J O forthwith comply with such pfovision of this Permit shall k deemed invoked.
Z" CONSTRUCTION LENDING AGENCY
Ihertbyaffrm Nat Nem iso comwctinn leadingagenry far the pcifurmanceuf
6i Ne weak fur which Nis permit in issued(Sec.3097.Civ.C.)
C Q lenders Narw
Lenders Add.
V Q 1 ceni(y Nat 1 have read this application and stave that Ne man information is
It, F comm.I agree to comply with all city and county ordinances and state laws relating to
�U building construction.and hereby auNarim representatives of this city to enter upon Ne
r W above-mentioned property for inspection purposes.
(We)agree to save.indemnify and keep harmless Ne City of Cupertino against
.Fes T0.A liabilities,judgments,Cosa and expenses which may in any way accrue against said City
O Zin Consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL Issued by: Date p (r^
SOURCE pT
sgicofA: /
L� J
Re-roofs
pm sc _
HA AR OUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant or future building accupantstere or handle hansdous matenal
ss defined by Ne Cupertino Municipal COM.Chapter IF 12,and the Health and Safety
jiftode.Section 35532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yat NO
70voiWill the applicant or future building accupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit havardous sit concomitants az defined by the Bay Arca Air Quality Managcmco all new materials for inspection.
c
istrict?
❑Yes Nu
1 have mad Ne hzraNams inactions regaimmen s under Chap er6.95 of Ne Califor.
ia HcalN&SafetyCOM,SCCWm25505,1551J andnS3 .1 un,kn and thdif the Wilding
oes not currently haw a¢rant.Nat it u my reaponaibility w notify the occupant Of the
yv"Con mnmm natpdor iasna.earacerorcatearaeaPan Signature of Applicant Date
r Oraathanr age¢ /D,teI All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: �Q3 ! PERMIT # /
(05_ //0 /5
OWNER'S NAME: PHONE # ?-53-1/ _3 -7
GENERAL CONTRACTOR: n �_ FAX #
I am not using any subcontractors:�flp (9h* 4,k �� a
Signature Date
Please check applicable subcontractors and complete the following information
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
e 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 I
n
,P�
Owner/Contractor Sign tars e Date
CITY OF CUPERTINO
tC-(- TEMP POWER
$CUPERTINO PERMIT APPLICATION FORM
APN# -3 2 ,o - 0 1 3 Date:
Building Address: Z V F3 I
Owner's Name: Phone #:P-53
53 _1137
C nt /moo `X /�- Ph e: License #:
a z�v z� vv Z,9 G
Cont c� n� Phone: c� � Cupertino Business License#:
Building Permit Info: Ar-
Elect
rElect
Job Description: I 11 (Qa A-M
Residential Commercial ❑
Cost.ofProject:
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
7