06070141 (2) CITY OF CUPERTINO ,Ar+°3xw;. fix)• r ^v4' "� ' "
BUILDINCDPERMIT 4 dIVISION = CONTRG'itC1I2IFTk'..URMA.TI(.}. «.�
y' , "z&:C"w •a t,{. ra`Yt"in s> <,.reset. .5 n.r
BUILDING ADDRESS: s PERMITN0.06070141
18661 MEDICUS
OWNER'S NAME: PERMIT ISSUE DATE
MOHAMMAD SAMI 07/21/2006
NE: SANITARY NO. CONTROL NO.
ARCHTLRCTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT l� O PLUMB MECH
O 0
lop LICENSED CONTRACTOR'S DECLARATION IOW Description
15
I�+F I hereby"m that 1 am licensed under provisions of Chapter 9(mmmeneing p
iwith Bolden 700th of Division 3 of live Business and Pmfensiou Code.and my Wersse4
in full farce and effect TEMPORARY POWER POLE
Z Licenm Clue Lle.N
Dom Comeamar
ARCHITECT'S DECLARATION
1 understand my plans shell he uted as public records
h U
G LiccnmJ Pmfeuionel
t.n OWNER-BUILDERDECLAontracN
I hereby affirm that 11. exempts ar the ConnactCo Lleense Law far the
400 fallowing muon.(Satan]fDmur t,alseu and .kne us Calc:Any m m mumy
19 which its brown,
•permit n cnnmmct alar.op..do Permit
t nr mpoig any anterum $1000
•z� pdorm iuiensedpreamquime the applicant forthe such Conpermiuo Bis asignedmatemcm
l� that(comma cccnsedPurwantotmofDimonsoftheConrmncesandPropLaw(CASE 9 Sq,Ft.Floor Area Valuation
m lawn US
in Sold.7000)ofelams for
of derpdexsminam Any
CASEor
`s$ Nat k 4 avmpt therefrom and the hula for the AlegW exempt(am Any Nolatbn N
Section 7031.5 by any applicants per a permit mbjece,the applicant to a civil penalty of - Occupancy Type
Ut mart tun Rw hundred dollen(55001
❑I,of owner of W property.or my employees with wags u hk4 m4 mmpevatan,
u ii W de work and rhe Sentence 4 ret Intended oaf seed for Salo(Sm.7064,Business
and Profemons Cade:The Coovumrs Lowe Law dao WE apply te an awoer of Required Inspections
property who build or im paws themon,end who does such work himself ser through his
own employee,provided th asuch Improvisation arc not inunded oroaen d forsale.It. ��
however,the Wilding w Improvement 4 old within ane year of cwop4don•the owner.
Wilder w10 haw the burden of proNng Wt he did ret build or Improve fw purpose of
ale.).
El 1 u owmr of the property,am exclusively controlling with IaMml mnuacwra wAIA (y /p
construct the project(Sec.7014.Business and Professions Code:)The Centra sues LI-
cause Law does an,apply he an owner of property wW builds or Improve thereon,ad
who mmuracol far such projeeu with a eonuacoms)licensed puruml mthe Conuseo's , � vJr)pyry
Lim.Law. 21180
tem ex Lunde tt _ Bk PCfw d4 mawo
❑ 59 o y5 yµT
Owner �Jso•=/eaR�"�' D.a� r) e0��.\
WORKERS COMPENSATION DECLARATION
I hereby aBlm under penalty of perjury ane of the following dclantiam: \1JI
1 ham aha will maintain a Certificate of Conaem to self-Imum far .WoullesCompcn-
da
sen,u provided fw by S on 3700 of the lathe Cade•fw toe perfamanm of de
were for which this permit Is issued.
❑1 haw and will maintain Work es Compensation Insunnm.u required by Section
3700.1'the Lahw Code,for the performance of the work for which this perch is Wood. '
My Wafter Campenaatov Inrorance artier and Policy number ere:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
COdssectlU Used not be cwnpload Ede permit 4 foam hundred dollen($IDT
or less.)
1 certify that In de peritoneums of the work for which this permit is issued,I shall not
employ any pcnon in my M2!r an as in bmamrblect m de WmrEmUCom�e m1
Laws of CaliforNt pate �•w3 a
APPlkant
NOTICE TO APPLELE6irif,.kMrm�einge�nire�-
of Exemption,you Should
become subject in the Werkefs Computation previsions of the Labor Code,you must
.JO foldwith comply with Sch provWons Or d4 permit shall k deemed eavokcd.
Z,rCONSTRUCTION LENDING AGENCY
[-te.
•i 1 Mrahy Alien der them 4 a construction lending agency for dm Performance of
IYi 7 the work for which this permit is issued(Sec.3097,CN.C.)
dQ Lender's Name
i7. z Larches Address
U O 1«stfy shat I have mad this applieuon end sum that the aWw infomnien is
Ly F comer.1 agree w comply with all city and county ordinance,and state laws rotating to
OU building consuuation,and hembyaudonm rcprosentatiws of this ciry•mcnmr upon the
Ushove-mendumed property far inspection purpmes.
t,•i (We)agree to save,indemnify and keep harmless dm City of Cupertino against
y liabilities,judgments,calm and expenses which may In my my acme against said City
U 7 in consequence of the grmtng of this permit. G'
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S0CE R ULATIONS. ��J / ��/2
lI/,46 /.� Re-roofs
Si awm of ApplleanKmorame Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicant or future Wilding occupant mom or bandle haumdous W ocrW
u defined by Jc Cupertino Municipal Code.Chapter 9.13.and Joe Health and Safety
Cecil,Some.25533(a)7 � All roofs shall be inspected prior to any roofing material being installed.
41 ❑Yes C3no
Will the applicant ser fuum Wilding occupant use equipment ordCOUS,whish If a roof is installed without first obtaining an inspection,I agree to remove
emit haerdnus air mnumiewls u depend by the Bay Ama Air Quality Management all new materials for inspection.
District? -
You Ip Nu
In w,mad the huardmsmatcrla4mquiremcnu umkr Clupmr6.95 of ft Caiifor.
n4Halthd:Safcty Cadc.SUtians25505.35533a 25534.1urImrtundthuifdm Wikgng
Jam rot cumndy haw a mnmt.shat It 4 my mspousdility m ondry dm amupant or thc
myulm , he muck met ptlorm R{u afaC Rcamof Oc pucy.
'_r—�Yls ry Signature of Applicant Date
'/ 0 7—-2 All roof coverings to be Class"B"or better
Owneror awhameda ort Dote'
Community Development
10300 Torre Avenue
It
zlto
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
4JUPERTINO.
Building De utment
JOB ADDRESS: a� c T CG d
APERMIT # 6o71 D (/4 r
r $�6� il'GS'
OWNER'S NAME: Ifn PHONE # T ]-
GENERAL CONTRACTOR: Mo Am a �,i' FAX# -L7—
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 A e e e� ` Y �-
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
!m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 37526006 . 00
DATE ISSUED. . . . . . . : 07/21/2006
RECEIPT # . . . . . . . . . 35332
REFERENCE ID # . . . : 06070141
SITE ADDRESS . . . . . : 18661 MEDICUS
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : MOHAMMAD SAMI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : MOHAMMAD SAMI
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
�EE 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
----------------- --- --- ------ ------------------
CHECK 100 . 47 107
TOTAL RECEIPT 100 . 47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
•
CITY OF CUPERTINO oW-70141
TEMP POWER
CITY Or
•cUPERJTINO PERMIT APPLICATION FORM
APN# 315— �-O' _ ,,/ _ Date: 7/24
/ P6
Building Address: P O(Jfy ' /
661 ple� C 14 C T `�e'err ✓o, cn -9,'0 IV
OwnerHN040 111" � 110n Phoiy #
Contractor: Phone: License#: Q �p
UM l� cv�11'2eu CTi;V t /VC 313- 76
Contact: S�� Z Phone:�o97_ Cupertino Business License #:
g-z ��ypj
Building Permit Info:
Elect 9?"
Job Description:
Residential Com ercial ❑
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
•