12080007 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10305 MORETTI DR CO,INTRACfOR:CIIETAUD PRO BUILDERS PERMITNO: 12080007
OWNER'S NAME: ARORA BRAIESI1 63 KENNEDY AVE DATE ISSUED:08/0212012
OWNER'S PHONE; 4083131030 CAM PBELL,CA 95008 PHONE NO:(408)313-4030
❑ LICENSED COQ 1'RACI'OR'S DECLARATION BUILDING PI--sRAIIT INFO: BLDG r ELECT r PLU\113 r
License Class 3 J rLic.4 Z "A
��// MECH r RESIDENTIAL r COpINIERCI,\L r
Contractor Date—1 /-Z
I hereby al� n arllicensed muter l he provisions of Cha pier 9 JOB DESCRI PTION: INSTALL TEMPORARY POWER POLE(Io0AMP)
(common g with Section 7000)of Division 3 of the Busi ties%S Professions
Code an That my license is in full force and effect.
hereby affirm under penally of perjury one of the following loo declarations:
I have and will maintain a certificate of consent to sell'-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
perforance of the work for which this permit is issued. Sy. PI Floor Aren: Valualion:S 150
I have omd will maintain Worker's Compensation Insurance,as provided Ibr by
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued APN Number:37514005.00 OccupancyType:
APPLIC,V FCEIt'1'11ICATION
I certify that I have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep brainless tile City OfCupertino against liabilities,judgments. 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may aeon•agains �id City in consequence of die
granting of this permit A iti It p cat understands and will comply
with all non-point sourc a is er Cupertino Municipal Code,Sectian Issued by: Dale: -�a-
9.18.
J
Signature Date b G
i
r Rh:ROOFS:
❑ OWNER-IIIIILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
hereby affirm that I am exempt from the Cuntracrr's License law for tine of inspection.
the fulltia'ingbvo reasons:
I,as owner of the property,or my employees with wages a5 their sole compensation. Signnmre of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sce.7044,
Business d Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR IIE'I-I'ER
consmucl time project(Sec.7044,13usiness-Professions Code).
1 hereby affirm under penally of perjury one of the fullo%iing three IIA%ARDOUS MATERIAL ti DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.9.5 of the
m I have Turd will maintain a Certificate ol'Consent to self-insure for Worker's California 1leulth S Safety Code,Sections 25505,25533,and 25533. 1,01 maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code.Chapter 9.12 and the I Icaltb S
performance of the work for which this permit is issued Safety Code.Section 25532(x)should I.store or handle hazArdous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants its defined by the Bay Arca Air Quality Management District I will
maintain complian th the Cupertino Municipal Code,Chapter 9.1.and the
permit is issued. Ilenhh S fray I lions 25505.25533.and 25534.
I certify that in the performance of die work for which this permit is issued,I shall
not employ any person in any manner sons to become subject to the Worker's Owner au .agent:
Compensation laws of California. If,after making this certificate of exemption,I hate:U Z Z
become subject to the Worker's Compensation provisions of the Labor Code,1 muss
forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUC`fION LENDING AGENCY
3 I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and stale that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and state laws relating
jto building construction,mid hereby authorize representatives of this city to enter Leader's Address
upon the above mentioned property for inspection purposes.(We)agree to save
1 indemnify and keep harmlesslhe City of Cupertino against liabilities,judgments,
h costs,and expenses which may accrue against said City in consequence of the ,UtClll'I'IiCI"S DECLARATION
granting of this permit.Additionally;the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
I
i
i zog oc"3 67
GENERAL PERMIT APPLICATION M E P
EQ COMMUNI iY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 950143255 w q
CUPERTINO (408)777-3228 • FAX(?O8)T77-3333 •buildinc(c)cucertinO.ore I�I
ISC
❑PLUNe LNG MECI-La,NiCAL __LECTRSCAL ❑luSCE/LL_NEOUS
FROIECTADDRESS (I �N'4Z%-�
DWNER NA.� � va I PHONE Lf_V J✓I 3�D E+IAZLq ro1a�. cam. � 1
STREET ADD[1ESSfytj C� CrY. STATE.ZIPI ,.___+, FA.Y
CONTACT NAME ' ^ PHONE E-MAIL
STREETADDRESS \ LTTY,STATE IIP FAX
❑OWNER ❑ OWNER-BIRLOEt ❑ OWNER ACTT AeWTRACTOR ❑CONTRACMR ADEM ❑ ARCHITECT ❑E4GA`EER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMEYx o J LICENSE NUMBERR LIMISE TYPE �1 I BUS.LIC A
7
STREET ADDRESSp� r( aFE 7
I CiY.STATE.Zr? `_—' A I PHONE
ARC{TT<CT/ENGINEER NAME l� LICENSE NUNMER ,!G I BUS.LIC p
COMPA.NYNAME' I P-MA? I FAX
STREET ADDRESS I CIN,STATS ZIP I PHONE
BUDC)WG: COW.CcRC'IAL ❑ MULTI-FAMILY PURHOLAN DLTERFA AREA ❑ NO I PROrCT IN FLOOD ZONE YES I I�SmBL[%i ❑ YES
OESLYIYTION OF WORK
j`�1,/
TOTAL VALUATION: /. RECEIVEDBY:
By my signature below,I certify to each of the`'ll n [^ th proper.rywav
owner or authorized agent to act on the property Dez's behalf. I have mad this
application and the iniormadon I have pro
i a read the Description of`Mork and verify it is accurate. I ag c m comply with all applicable local
�
ordinaices and sam laws micros,,to buildi Lhorize mpresenatives of Cuperdne:c enm:d:e above-id 5e proe-./for inspection purposes.
Signature of Applicant/Agent � Dam: . z
L&)vM',c4Tt1,L INFO&NWTION REQUIRED OFFICE USE ONLY
v OVER-THE-COUNTER
EYI'RE55
rj
❑ STANDARD
V
< ❑ LARGE
❑ MAJOR
McP.Nuc4pp_2011.doc revised 06/21/11