08100143 CITY OF CUPERTINO
BUILG!NG pIVISION PE CONTRACTfTRINFOR�SAT,ION`'
BUILDING ADDRESS: PERMIT NO.
10452 nd R
OWNER'S NAME: INC. PERMIT ISSUE DATE
A CONTROL NO.
408) 370-1485
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO EO
P LUMB
MECH
O
Q 00 LICENSED CONTRACTOR'S DECLARATION
vj d C 1 hereby affirm Wu 1 un li¢NW under provisions a Chapter 9(commencing lob Description
<t� with Section 7g10)of Division 3 oldie Busixvs and Profendurs Code.and my lianmu
3oH hifnitfanxaad.Ben. TEMP POWER @EXTNG PANEL
7LJz tucnc Class Lic.I
-Fp Wm 9. n? Comrxm leAre_
ARCHI'IECTSDECLARArION
: 1 understand my platy shall W used u public records
to
I'C 17 Licensed Professional
jOWNER-BUILDER DECLARATION
<m I hereby alarm that I am exempt from the Commons License Law for the
00 following mamn.(Section 7(n 1.5,Business and Processions Coda:Any city Or county
S 2IL which requires a Permit m cnnmuct.slur.Wpmw.demolish,or repair any stNctum
prior b its issuance.atm acquires the applicant forsuch permit to Ole a signed statement
-Z<
that he is liccround purannolot the Provisions of the Contractor's License Law(Chap=9 Sq.Ft.Floor Area Valuation
Y0 (commencing with Section 7000)of Division 3 of W Business and Profession Code)or
y $ that he is exempt theref em and the b..:s for tiro alleged eumpdm Any violadou of 9250
Section 7031.5 by my applicant for a permit mbjcc s the applicant to a mB penalty of APN Number Occupancy Type
not mom than fnw hundred dollars(SM.
❑I,o he, a. . ad prapmty,m ter wpleyees w re wags a neo-tele cmnlmustim. 34229061 . 0 0
will da the,ewons sande: she ContsmUnumdcdmaRemdfo sale(Sec.7044,Bushsss
and Pa(CSLON Cade:The GaOtlaelnra I.IRRC Law da41 rat apply b an awller Of Required Inspections
property who buildaarimpow thereon,md whodoessuch workhiuselfm Waugh his
own employees,provided that such improvements art Out intended oroQerm farsale B,
howmer,the building or impnevernent is sold within one year of completion.the owner.
builder will haw the Wden or proving that W did Out Wild or imps.for purpose of
sale.).
❑1.as owner of the property,me esclusinly contracting with licensed examinations;m
comtmct W project(See.7044.Business and Prufcsaions Code:)The Contractors U.
ewe law does am apply to an..of progeny who Wilda or improves thereon,and,
w W eonuacu(testate Projects wild aconhsctorts)licensed Pursuant to the Canuxtor's
Licew law.
❑I am exempt under See ,B&PC fm this mason
Owncr, Data
WORKERS COMPENSATION DECLARATION
1 hereby aQure under pevalty of perjury ane of the following dreluaOaN:
1 have and will maintain aCerdfiam orcoment m self-insure fm Worker'sCmmPer,
On.as pmvidud for by Seetion 3700 of rhe Labor Cade,for the Performance of the
work far which this permit is Wood.,
1 have and will maintain Workefs Compensation Ineomec,as uquimd by Section
37W of the labor Cade.fmthe pcRornmct,ofW wort fmwhich this permit is issued. '
My Workers Compensation Inmrmm carrier and Policy number am:
Carrier.JTJfI1P Canto Policy No.: 7/.3-002 3YP9
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu seam need cot ho cmmpkred ifft C perm it is fm ore hundred doBace($100) .
Or Inds)
1 easily that in the perfmmancen of the work for which this permit is owed.I that not
employ any person in my mmncrso a to become subject to tic Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If, for making this Certificate of Exemption,you should
become subject b the Worker's Compensation provisions of the Labor Can,you most
,J O fuMwith comply with such Provisions or this permit aball Im deemed rooked.
Z 7 CONSTRUCTION LENDING AGENCY
t-n� IWreby affirm out the is a construction lending agency for tic perform.see of
Rvi W work far which this permit is issued(Sas.3097,Civ.C.) -
W Q lenders N.
Z Isndefs Address
U O 1 cenirr that 1 Ww read this application and sate this the shore i ul.aun is
E' comet.T agree to comply with Al city rad county adlnu es,and sum Ian relaxing to
DU Wilding construction,and hereby ausborise mpmeantatim ofthu city m emerupanW
W aWw-mmdoned property for inspection purposes.
0 (We)agree to save,indemnify and lu ep humleas the City of Cupertino against
Vl liabilities,judgmcma,tato and expenses which may In my way accrue against said City
u in consequence of the zooming of this permit.
�-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PORN' Issued by: Date 0—
SOURCE REOUL 3
1 Re-roofs
SignuumofA tan nZto Dau
H RDOUSMATERIALSDISCLOSURE Type of Roof
Will tmfuture Wilding attupmtsmre or handle haadons mauriai
sa defined by the Cupertino Municipal Cade.Chapter 9.13.and W Health end Safety
Cade,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
wn the app> tar future Wilding aawpem ate anointment car devices whim If a roof is installed without first obtaining an inspection,I agree to remove
it Imadnns
at cmumiNnts a defined by W Bay Area Air Quality Management all new materials for inspection.
men
❑Yes
I haw reulWadousmaurials requirements underChaVmti.95ofWCalifor-
niaHeslthkSafetyCade,sections 25505,25533 and 25534.1 unMrstsnd dhetifthe Wilding
does not currently haw a unan tit u responsibility to notify the uxuPant of the
requlmmcnawhiehmuaW a roan aanceoneedreaeorampanay. Signature of Applicant Date
oar _
Dome,ormmarirdr t Data All roof coverings to be Class'%¢"or better
CITY OF CUPERTINO
e 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . .. 34229061 . 00
DATE ISSUED. . . . . . . : 10/23/2008
RECEIPT # . . . . . . . . . : BS000006441
REFERENCE ID # . . . : 08100143
SITE ADDRESS . . . . . : 10452 MERRIMAN RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . . RAJ THIRUMALAINAMBI
ADDRESS . . . . . . . . . . : 10452 MERRIMAN AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JON R CRASE CONSTR
CONTRACTOR . . . . . . . : JON R CRASE LIC # 22250
COMPANY . . . . . . . . . . : JON R CRASE CONSTRUCTION INC
ADDRESS . . . . . . . . . . : 164 GILMAN AVE
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 370-1485
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 250 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1ERT>lK UNITS 1 . 00 71.39 0 . 00 71 . 39 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---------- ---------- ---------- ---
TOTAL PERMIT 153 . 47 0 . 00 153 . 47 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 153 .47 #51420
---------------
TOTAL RECEIPT 153 .47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER
CITY OF CUPERTINO
TEMP POWER
• CUPEQ NO PERMIT APPLICATION FORM
APN #j i� �y / U Date:
`/ j l Io a3 Dy
Building Address:
Owner's Na e: Phone #:
X47 AIA 1101 . 306 - S666
Contractor: Phone #: yo}'• ?7,* ,/Y8S
f J'L�ic/ST�Gr�u�or✓ Fax#: yvY 370 2 P, 3
Contact: Phone #:
.Py,�✓ rv�7,�,./ yol - os y
Contractor License #: 6'11-5-171-7
Cupertino Business License #: as 2 6-D
Job Description:
Residential Commercial El
Q
Valuation (cost of project): Type of Construction: N/A
Quantity Fee ID Fee Description Fee Group Permit Type
IERT>lK Res. Temp Power>1K E 1REAP14
Amps
1 ERT<200 Res. Temp Power<200 E
Amps
1ERT2001K Res. Temp Power 200-1K E
Am s
IEPERMITFE Electric Permit Issuance E
IELCPLNCK Electric Plan Check E
/ IBSEISMICR Seismic Residential B
/ 1TRAVDOC Travel & Documentation B
Fee
CITY OF CUPERTINO
TEMP POWER
CUPER,TINO PERMIT APPLICATION FORM ,
Quantity Fee ID Fee Description Fee Group Permit Type
1BSEISMICO Seismic Commercial B 10EAP14
IECT<200 Commercial Temp Power E
<200 Amps
IECT>1K Commercial Temp Power E
>1K Amps
1ECT2001K Commercial Temp Power E
100-1K Amps
1TRAVDOC Travel & Documentation B
Fee
1BUSLIC Business License B
Revised 6/16/08