05020118 (2) CITY OF CUPERTINO !!� �vas:#i1 �'+,�
BUILDING DIVISION PERMIT itco ?t°A. l»T Ik�INl' RMAy' IO' NN .
.vcstf. hha3Y
[BUILDING ADDRESS: NATIONAL CONSTRUCTION RENT PSS "(05020118
362 STELLING RD
OWNER'S NAME: FERMITISSUEDATE
KHURRAM I BAL 1355 FILIPE AVE 02/16/2005
14 NE: SANITARY NO. CONTROL NO.
(818) 221-6057
ARCHITEC tSNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
jcp LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provislou of Chapter 9(commencing p
�m with Section 7000)nfDiviaion 3 of On Business and Profcuinm Cade,and my license is
-ph in NH to. And G.,. TEMP POWER POOL
y YJZ L1ccnm Class Uc.•
3 FJJ
Data Contractor
e ARCHITECTS DECLARATION
C 1 understand my plans shall be used as public records C1--
r G Licensed Professional
S 5 OWNER-BUILDER DECLARATION
f 1 hereby aRre,that I am exempt from the Convector's Licence Law for the D ,
p o fallowing mason.(Section 71131.5,Business and Pmrensiun Code:Any city or county ice.
$ which requires A permit to ennsruel,scat improve,OCMOI sh.M repair My xtmcturo S200_
a t.^
prior o its issuance.also raquires the applicant for inch permit to file a signed statement
that he is licensed pursuant to Na provisions of the Contractor's License Low(Chapter 9 Sq. Ft. Floor Area Valuation
222 $ (commencing with Section 7000)of Division of the Business and Profession&Cmic)of
y, that her Is essmpt dmsefmm And the buil for the alleged exemption.Any violation of
Section 7031.5 by any applicant fm a permit subjects the applicant to a civil penalty of
not more Nan five hundred delta.(5500). 8 Occupancy Type
0 I,a ownm of the pmWny,or my employes with wages u the4 wlc compemation.
will do the work,and thesvuclurn is not intended maffemd fouAle(Sec.7W.Business Required Inspections
and Profeuioln Code:The Conmcmes License Law dos e not apply to an owner of q p
property who buildsar impmvea thereon,and who does such work himself orthmugh his
own employees,provided Na such improvements ase wt memiled or offered for sale.if,
however,the building at improvement Is mid within am year of Completion.the owner.
builder will haw the burden of proving that he did not build or Improve for purpose of
❑I.As owner of the property,am exelaively connoting with licensed contractors ut
convect the project(Sec.704)Business and Professions Code:)The Contractor's Lt.
cam Law dean not apply to an owner of property who Wilds or improves Neman.and
who contracts for such projects with a contractor(s)licensed pursuant to the Convector's
License Law.
0 1 am axe,m�Aundm Sec �\ (.L/�— B At P C far this rcaon
Ownei -L/IA--k A.a .._ �'x X Dam
WOR' I S COMPENSATION DECLARATION
J I hereby affirm under penalty of perjury ore of the following declaration:
I haw And will maintain a Cerbinta of Conant to self-inure for Workefs Cortin.
cation,an provided for by Section 3700 of the labor Code,rm the performance of we
work for which this permit is issued
❑1 have and will maintain Worker's Compensation Iwranm,an mquitod by Section
3710 of the Labor Code,for Ne peKmmmce or Ne work for which Nis Permit is Wood.
My Worker's Compensation Insurance carrier and Policy number em:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section mad not Mcomplemd i(Ihe fcrrall Is forane hundred dollars(1000)
or mss.)
1 unify that in the performance of the work for which this permit is issued,I shall rad
employmy worries,mannerw qlo keen subject to the Workers.Compensation
Laws of Califs DAm
Applicant A s AA_v r"\_ �
NOTICE TO API ICANT:IL afterma�g�This Certificate of Exemption,you should
become subject to the Workce.Compensation provisions of the Labor Code,you most
7z forthwith comply with such provision Or this Permit shot]W deemed&evoked.
M CONSTRUCTION LENDING AGENCY
1 hereby alrum Nal there Is construction lending agency for tla performance of
x ti the work for which this Permit is issued(Sec.3(197.Civ,C.)
A Lender's Namc
= Z Lender's Address
J 0 1 ceNfy that 1 have read this application and sum Ns who above infolmatiun is
y correct.1 agree to comply with all city and county ONinances and sum laws relating to
building construction,and hereby authorize mpreunuuves of this city to enter upon the
above-mentioned property for Inspection purposes.
(we)agree to save.Indemnify and keep harmku the City of Cupertino!gains
u,
y 1]Abilid )udgmenu,eom and exKAwm which may In any way accrue,Against Mid City .
J7 in consequence of the granting of this permit.
rr7�-
APPLICW UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC EGULATIONS. _
Re-roofs
Signature of ApplicmVContrwlor 1 Do
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hanrduus material
As10wrcr
defined by the CuPont Municipal Cada.Chapter 9.11.and the Health And Safety
owe.Sccdon 75531()? All roofs shall be inspected prior to any roofing material being installed.
OYu l .-
Will the applicant or(sacra building=upon(useeyuipmcntardvicm which If a roof is installed without first obtaining an inspection,I agree to remove
✓ It hautdnus air contaminants u defined by the Day Area Air Quality Management all new materials for inspection. '
�✓ iasics7 '
❑Yes
Ihavc mW the WUNnusmamrlels mqulmmcnu under ChaPmr 695 of Jm�ifoa.
a Health ASafny Code ScsvounS05,15533wd25534.1 underseadlhatifthc Wilding
os not c randy how a Conan that It k my nespon hility b nouly the occupant of thc
qulmm which musMmet prisrwivuMce,ofaCcnifcatearoccup cy. Signature of Applicant Date
as AAthmivea Agent Dac All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
aCITYF
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
,UPEI�TINO
Building Department
JOB ADDRESS: PERMrr#
6 S-ce1vo3'a 2, )�
OWNER'S NAME: PHONE # 12
GENERAL CONTRACTOR: ow FAX #
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
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
gt7TEMP SOWER bS18
- �,/l�
� OF
CUPERTINO PERMIT APPLICATION FORM
APN# b� I ( o S� Date: 2 —/,4, _ Or
Building Address:
13) ' \
Owner's Name: Phone #:
1
Contracton4 Phone: License#:
Contact: Phone: Cupertino Business Licepse#:
Ktiv RAt� At_ �la� $ ti
Building Permit Info:
Elect
Job Desc ption:
Residential Commercial ❑
Cost of Project:
•
Qty. if
Applicable Fee ID Fee Description — FeeGroup
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License - BUILDING
p—o 1