06020104 CITY OF CUPERTINO +,«aascaw�e
B n Dlnc Dlvtslon PERMIT CONTRACTOR tINFORMATION �t
�. � ,d„ t
BUILDINGADDRESS: NATIONAL CONSTRUCTION REN AU9No 06020104
18820 BARNHART AVE
OWNERS NAME: PFRMITISUEDATE
BALAJI SESHACHALAM 1355 FILIPE AVE 02/17/2006
NE: SANITARY NO. CONTROL NO.
i (818) 221-6057
ARCHOECT/ENGINEFUH:
BUILDING PERMIT INFO
BLDG ELFCI' PLUMB MECH
] 0 0 0 0
Yo 0O LICENSED CONTRACTOR'S DECLARATION Job Description
I mrtby affirm that 1 am Maned uWer provinans of Chap=9(mmmcrcln{ �YA nn
It Secuoo xicfof Diviilon Jo(tm Buurcat oral Pm(usluu Cade,oral mylicrneis ALE
E
inrwuomeamercan TEMP POWER POLE
'LIE Lkxna Clav Lie.
Dale c t.
ARCHOECTS DECLARATION
�i 1 uhdtc=rd my plains"I he mad u(public rtcm& f (r i] V-
�pN fi:amcd Pm(usi...I r, U 2006
OWNER-BUILDER DECLARATION (j�I r■y R y
aC a 0 I hraam _(iron aw I M uunp form am CmneamC :Any c Law far tc BUN
p r AA 1 S O
p 0 follmving masa(Scum 703I3,Busimu.rd Pmfnvum EWc:Any city a counlY +`� LLLL /l, 'p to
$ which mgueu a pertnit b amsWc4.ha,impm.e,dcmwuh,m rydr any.vocwrt al C-Itle
—
_zi primo iu iron.=m,.,..almrt uirate.pplieantformch permitb Bleaaigt�aubmem
< t.tMuliamcdpyw.nllnNcryorlabuaflhcConincbrilhcvcl�w(Gapia9 Sq.Ft. Floor Area `Valu'etiori
$
that
ha I.ingwit Surf.and
of laicaion3 e<Im Bus udmpod,My iCale)ar
— thu m u comp Ihacfrmn aM the buts far UIc.legal eamplaa MY vlol.t3on of
Semon 7071.5 by my applicant fm a permit subjects lm.PPBmn to a Civil puLLy of t Occupancy Type
am more that bamrtd adl.m(ssooa
❑1,as owner of ft podpm,m my aoploym with wwru u thea mLL cmopm.alnn,
wW all the wah,and to msumurt a wt hooded m Offered fm We(Sec.70M,Bam. ns Required Inspections
and Pro mounts Cade:The Coarmcro's Liame Law dots nm wWy b an owner of q P
papacy who builds aimpmea Lemon.anal who daesauclb wvrkhimvJfm Waugh bia
owns anployas,pmWdeA IW smh imptm cmems an,am Imertica mWtmdi for axle If,
however.the building m'unprowmenr Is said wltm arc yv r of mmplation,the ow ar-
buildo will h..e the burden of poring that k fid nor b i Or Improve for puryoe of
sale.).
L u mwna of do pmpcny.am eac1=dwIy cmnb.ming with Bmued mnmcius b
cvoc v t the pojlzl(Sec.70x4,Buadaea mot P.(=.Coda,)The Coao- .Li.
avec Law dots na.pply to an owns a pmpny who Wit"«impo.es tiertan,and.
who cmnaau fors pojccts with a cmm.cbr(s)Ikaaa¢d puauant to Na,Cmmr.mofs
rut,Law.
❑lam tmatr ,B&PCf tui
Due
SATION DECLARATION
I homily rpuWryorprjury me of nr folWwing dee
I tu.eand will Wn a Ccrufi=Of Cavea b ad(-msura fmworka's COmpen�
tidos,n pmvidOd fm by Section 3700 of the lahm Code,for the pmformmcd of thc
wok for which Nis prmil n Lsmed
1 have aW will molal.Wor1tt's Cdrn c dam Imumco,as rty Bred by Sermon
3700 a the Mbar COJe,for Na,perfarmana m(tc wk for which WL parmll u Loved.
My Wortrh Compensation I. .rcs curia and Policy number art:
Curie Policy No.:
CERTIFICATE OF EU(EMPTION FROM WORKERS
COMPENSATION INSURANCE ,
rrEa xcfind rcW ambcwmpleob ifft pmrna u formic huadred annus($100)
m Ira)
1 cau( that in the pMurmana Na,work for which this p h u iitmcfi,I ahall tam
cmplor,my'tion in mature tib bec!lubiact to tc Wan' mpcfind
Laws of Cilifomu.D
AppB t
NOTICE TO APPIUCANT:IL�n Ccnif .r Eacmp���
become subJat b Na,WarkeYa mnp�pmviaom mf Na,lobar Code, vaum
.,Z fanhwith amply wit such is i an permit shall m damcd revatrd. - -
Z'O CONSTRUCTION LENDING AGENCY
I homy Drum am there u.coaeuuakn lading agmrcy fm tie I cf.of
Ni > to wart for which thu'omit a' d(S 3M.CH.C.) .
Uj 0 Lcoam"Narrc
J Z L.L,'a Add.
U O 1 cenify that I have rvd W s.010. .and static that the.hove mfmm.uun u
W E mrrtn.I,"b cOOIPIY with 91 City Ind cmumY mdiauo'es.nd nate laws relating to
C) m0ding cmnmrmcdan,wd hemAy auhanna reprucnuu.es of thu city to enbr.,,on to
W .Mve-=mnocd pmpeny fa iupcuan pmposea
Q. (Wc)agree to ave,inecmm fy and trop barmkss the City Of Cupemno.g.lmt
V) lubilioijudgmem;costs and eapcnaa which may In any way.muc.gainn laid Chy
U in cwarym=Of thc gmming of to PermiL
.. APPLICANT UbfDERSTANDS AND WILL COMPLY WITH ALL NON I Issued by: Date -o6
SOUR TIONS. h
V Re-roofs
Sigmas,..ofA VCmn
H WS MATERIALS DISCLOSURE Type Of Roof
Will tho applicantAkworeW ng meapa lmart orhardy h—n! m.erW
u c1clincd by Ion C Mmi j al Code.Ch.pa 9.11 anal the Hulth and Safety
z'S�on 25$32(')7 t�Tio All roofs shall be inspected prior to an roofing material beim Installed.
pYca Pe P Y B g
Will ft.p I.(or I..mowing..,m tie e9Wpmam m deviaa which If a roof is installed without first obtaining an inspection,I agree to remove
It huaraaaa air coma nhumu o load by the Bay Are.Air Wuity Mmugcmcnt all new materials for inspection.
osses
D ?
❑Ya
I bona rod tc baautus mucriala r.Virc.mi Intk,ChV 6.95ofNa,Cilirm-
nia Health&Safay Codc,Sccdom 15505,75577lad 25531.1 ondarstvd that irtc botching
d rat rnently haca Lto It is my rc mmaility tom fy ton=t,am of dr
r,ofum,rmou sat IPmxW' w,cwniteof Signature of Applicant Date
owner m m,tmiae.g t D I All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
j,m
am' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPERTINO
Building De artment
JOB ADDRESS: �� PERMIT L
hbbtzVo 2
OWNER'S NAME: Fkj
k PHONE #
GENERAL CONTRACTOR' 5-7" 7 FAX #
I am not using any subcontractors: 2 17 9
Sidatuxe Da
Please check applicable subcontractors and compyete the followinginformation
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
Z
ng
ank
etal
ock
06
Owner Contr for Signature Date
CITY OF CUPERTINO
g, TEMP POWER �� Z—,)
CIN OF
CUPEkTiNO PERMIT APPLICATION FORM
APN # I Date: o l 6
Building Addres
Owner's Name: Phone #:
1-31L4Jr5-Em C,
Contractor:' P one: License #:
Contact: J L _ Phone l ` �I Cupertino Business License#:
Building Permit Info: (o
Elect
Job Description:
Residential Commercial ❑
Cost of Project: �0
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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