05110122 (2) CITY OF CUPERTINO ,
P'-U1BUILDING DIVISION PERMIT ,CONTRACTO;R?TNFORMATION
53
LDINGADDRESS: OM BUILDERS, INC PERMITNO.05110122
OWNER'S NAME: PERMIT LS5UE DATE
KROTHAPALLI ANJANEYULU & KJMAR37053
NE:
SANITARY NO. CONTROL NO. .
510) .744-1085
ARCHI ECrfENGINEER: BUILDING PERMI'TINFO
BLDG ELECT PLUMB MECH
�_ � n / O O O
`uO
mm ttUCUai CONTRACTOR'S DECLARATION JObPhenPTIp1 thereby affirm that I an under Nrtr 9(commencing LED
on
with Section 7")of Division 3 argue,Business and Prole ions;wdea,and my licensee
<= infullfomeandcff 77 -5 TEMP. POWER POLE
j=i ,n o Class ' Lie.N
o Dam Genre der APR a-;X-2006
ARCHITECTS DECLARATION
- I uMnu
enJ my plans shell M a used public rtcorm
3
p d u r'rjrl�JNp,LIpl\J`7ft!)]d {}�. rl G r
Licensed Professional frj.JQ—/S�1'(FJ)ga yen\)���1
OWNER-BUILDER DECLARATION jNJ
q I henclayMaso .(Son Nal 1 1. exempt from Ne Conumctor's e:Any c Law for de
p O following mann.(Section 71D 1.5,Business and Re.dim a Code:Any city ear county
5m to which ets issu a permit re cores him pboar.plic bnpmsu dem lair L fie pair any sunmad ame•wearmaill C, 0
iy than hor e iuiensedprsunttance.also o ft him
so for such panni'¢ciona aw(Clip=9
< Nommenctt with
)of vii.mofNeConumads lhzvcssorChapm9 Sq.FC Floor Area Valuation
eFC (commencing with Section 70M)of Division lnf the Businev and Professions Cade)or
tn, $ that he is exempt sWmfrom and the base fee the alleged exemption Any violation of
Section 7011-5 by a%applievn for a Permit mbjccu the applicant to a civil penally of
amt mom Nan filo hun io d dollen(SM. g Occupancy Type
D L u owner of Ne popmty,m my employees with wages as their mlc comp orchimn,
will do the work and Ihesseeetud Is notin¢nded oroffeed forsslo(Sec.700x,Business
and Professions Cade:The Ciumpcmr's Limn¢Law dams sent apply m an owner of _ Required Inspections
paperylona loammirephaseschImr andwho aurasuchwork muff ¢through he
awn ver.the Wilding
Nattechimpmwmmuartnot easMNmoReed reissthe
r.
however.the building or improvement a sate within one year of completion,proor Ne owner-
insider.). HB have the Wrdm of proving that M did rot Wild m improv for purpose of
sale.).
D 1,a owner W the property mm exclusively cmuacting with licensed contractors on
construct the pmjca(Sec.7004.Business aid Professions Cade:)The Contractor's U.
cense Law dao not apply in an ower of Propenywho Wilds ar improves thereon.and
who¢ounce Intranets pajeea widea common r(s)licensed pursuant ta dee Conumme.
License Law.
D lamemmptunder See .B&PCrarasemawn
1111w"
ner Dae
WORKERS COMPENSATION DECLARATION
1 hereby of irm under petWly of Perjury one of the following docauatimer
I aaveand will maintain a CeniGaam ofConsent to self-ivurt fmWorknesCompce-
an.as previded for by Secdan 3700 of the L+Wr Com,far ae parforman¢of the
rt for which Nis Permit a name.
1 have and will maimam Worker's Compensation Inman¢,as required by Sectin
We(the la W,Conn.In,dee,performi.d.f Ne work far which Nis permit a issued.Worker's Coccmprtai himrarnz carrier and Poliry number am:
rtier. 1'Y J7��� Policy No.:
IC RTI-F OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Dm mire need act las compleed if the Permit is fm one hundred dollars(SIM)
or leu)
1 certify that in Ne performance,of the work for which this permit is issued,1 Nall not
cmploymypermnin any mmnerso mbccpme/.�{,)ectm Ne Workers'Compemauan
laws of CalifomiaDam�I,T�31
Applianl
NOTICE TD APPLICANT:IL ri&r meati Ne Certificate of Exemption.you should
become subject m the Worker's Compensation previsions of the Labor Coag you atm
.J O forthwith comply with such Provisions m Ne Permit Nall be doomed evoked.
Z� CONSTRUCTION LENDING AGENCY
[--� 1herchyafrum Nat than,its emseruction lendingmgcacy,far Ne performance of
Ne murk for which this permit is issued(Sec.3097.Civ,C.)
WhQ Lander':Name
=Z lender's Address
V Q I«nify Nat 1 haw read this application and sum Nat the shove information is
gL f'• carrccL I agree in comply with all city and county ordidi and fart laws Miadng On
C U Wilding consuucdon,and hereby mthodm representatives of Ne city to enmrupet Ne, (�\/t�(./��//
�+ a shove-mcntiarred property(m impectim Puryotes 1/""C/VCJV .
(We)agree to saw,indemnify and trop harmless Ne City of Cupcnim agairat
ani to liabilities,fudgmcmu.cats and expenses which may in my way ammo again sed Cit,
U Z in canguerec of the granting of Ne panni.
^ APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date �---
SOURCE REGULATIONS.
���a Ll� Re-roofs
Signazurc ofAppaicanPC.n r r Olin,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will site ateplianl m future Wilding omnpanl store or handle hanNous material
as defined by the Cupertino Municipal Code.Chapter 9.Ix,and the Health and Safety
ende,sawn xss3xa)7 All roofs shall be inspected nor to an roofing material being❑res QNen P P Y g g installed.
Will Ne applicant or future Wilding msupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hanrdous air contaminants a defined by the Bay Arta Air Quality Management all new materials for inspection.
Manic,?
Dyed 19 NO
I have read the hvardens mmerials mquiemena under Chapter 6.95tefthc Califor.
no Hcuarh&Safety Code,.Sections x5505,x5533 amt 25534.1 understand Naz if ae Wilding
does net curtenay nae a enm.that it a my responsibility m netify dee occupant of 1W
.quernanu whichnotpsar to ismanee on Certificate or arty. Signature of Applicant Date
61
Owner or authon=dWn,
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
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
51e, '� 05; l 2—
OWNER'S
OWNER'S N PHONE # p�
GENERAL CONTRACTOR: yt, FAX # / p
I am not using any subcontractors:
Signature bati
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
, S TEMP POWER
CITYCUPEIZTINO PERMIT APPLICATION FORM
APN # G /l Date:11
Building Address:
Owner's Name: t Phone #:
Contractor: Phone: License #:
Conta t Phone: , r Cupertino Business License#:
okFAN S ,1Zw� A Sl SS - I�Q a
Building Permit Info: 1
Elect T�nAodLA�1 6 1�
Job Description:
Residential Commercial ❑
Cost of Prcjec
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Tem orary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
� � e> 35,