05090168 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT r COV'�TRACTURTNT!'�'RVIA'CIOi
BUILDING ADDRESS: ALVAND CONSTRUCTION PERMIT N0.05090168
22561 RICARDO RD
OWNER'S NAME: PERMRLgUHDATE .
RAY NEZHAD 10413 TORRE AVE. 09/26/2005
NE: SANITARY NO. CONTROL NO.
(408) 781-7620
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG 1= I�BLECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION dr Job Description�+ i hereby affirm that 1 am licensed under previsions of Chapter 9(commencing
with Section 7000)or Division Sof me Business and Professions Code,and my license h
n� mmooClas, rceeL v yi S TEMP POWER POLE � ��®
C$z Lfulll CWs - Lie
S ARCHITELTSDEC ATION
Q 1 understand my plana shall he used an public mcmds
Licensed Professional SEP -2-� 2005
OW NER-BUILDER DECLARATION
I hereby affirm that I em exempt frem the Convector's License Lew for the
O O following recon.section 7031.5,Business d Professions Code:Any city or county
$ which requires•permit to convect,altar.improve,demolish,areair an Amuc um
Pdorm its lauaac,atau requires the applicant forsuch permit write asigned moment
that he is licensed pursuant o me previsions of me Contractor's L'cene Law(Chapter 9 Sq.Ft. Floor Area a Lx3antSV IOattOl;_�
(commencing with Section 7000)of Division 3 of be Business and Prefusiom Code)or
Out he is exempt Ihmfrom and the basis for me alleged exemption.Any viotadon or
Section 7031.5 by airy applicant for a pannit subjects the applicant to a civil penalty of erw u Occupancy Type
not mom than five hundred dollars($500L
❑I,u owns of tha pmpwy.a my employes wire mgu u mW mlc eompewdon,
w nm mews
and es lCWs:eThe Cm seve's License Low dcdes faan,aapply tlfan owner of
Required Inspectionsections
property whobuldasirImpmwnesdemon,ahawho dssuhwk himred theauSh his
manemployces,provided mss such Impmwmare an,lose offered foeale ,
however.the building or imprewmmttamidwt arecurofcmeuftheownee-
builder will have the moment of proving that m did.1 Mid or improve forpurpose of
um.).
❑Lo owner of the property,am ucl.,hMly conbU9ng with licensed convanon to
construct the prefect(Sec.7a4,Business and Profession Code:)The Con rmtor's LI.
cents Law does not apply An an owner of property who builds or improves thereon,and
who contracts for such project,with a eantnctor(Q licensed pursuant to the Com unme,
License Law.
❑1 am exempt under See. .B R P C for this moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby afro r under penalty of perjury ane of the following declarations:
I have and will msinuin a Certificate ofConent an Ulf-luum for worker'sCompen-
antion,As providN for by Section 3700 of the labor Code,for the performance of the
work for which this permit is Issued.
❑1 have and will maintain Workers Compensation Insurance.As required by Section
37M of me labor Code,for the performance of the work for which this permit is IAued.
My Workers Compenuum In eartia and Policy number sm.
Gmer. -34". Polity No.:
CERTIFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
comm mcum need ret bo completed Hire permit Is fmonehundmd eoilsn(SIM)
to less.)
I cenify met in me performance of me work for which this permit is lased.I still not
employ any person In any mannerm As In become subject to the Workers'Compenudon
Laws of Califomla.Data -
Applicant
NOTICE TO APPLICANT:IL after making this Cenifram of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cents,yen mum
.JO forthwith comply with such provision or mu Permit be dcemed maked.
ryNiCONSTRUCTION LENDING AGENCY
E-s l hereby arfrm that 0mm is a construction lendingagency for the Porfarmane.or
a be work fur which this permit Is issued(Sec.3097,Cih,C.)
W Lender's Name
az Landers Address
U0 I certify that 1 haw and this application and mate that me above informadun is
14 E+ come%.I agree to comply with all city and county ordinances and sum laws rotating to
OU building conswnion,and hereby anmodea representatives ofthis city to emcruprn be
W above-mentioned pmpeny in,Inspection purpose,
G (We)agree to taw,indemnify,and I¢cp harmless he City of Cupertino against
y IlahilideAJudgmenm,cess and expemu which may in any way amue againstsud City
U in consequence ordure Swung of that pemuL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 7j 4"O (J—
SOURCE,pEGULA 0 S.
Lj_ Re-roofs �s�. 1iC
Signature of ApplianucanumYor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will mo applicant or future building oavpanstore a handle hauNom material
As defined by the Cupertino Municipal Cade.Chapter 9.13,and the Healb and Safety
side,Secuon 35533(.)1 ef All roofs shall be inspected prior to any roofing material being installed.
0Yu Nu
W11be applicant sir room building occupant tae equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
h hazardous Air common nIs o fined by the Bay Area Air Quality Management all new materials for inspection.
uict7
❑Yu Nu
I have mad the ha>ardammemriatamquimmenu under Chepmr6.95 ormc Califor.
nia H..Ith&S.retyCode3ectiom25505,25533uu135534.lundeuundthmifine[wilding
dean not currently have a mnant that II is my responmldlby m nouly the eecup rm of the
mquimmost yytiylmu creat Pdorwiuummofacemre.marampmey Signature of Applicant Date
'C/ ' All roof coverings to be Class"B"or better
Owner tar emhod Ad agent Dau
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aCOF Fax(408)777-3333
IUPEkTINO
Building De artment
JOB ADDRESS:2 2 SG 1 1`tcgr�o iQ4PERMIT # 6-5-u7 o
0 0
OWNER'S NAME: t&A,kti4 PHONE # Cy o 8
GENERAL CONTRA R: A I v 1,,4 Cb �o-,, / FAX# ( o 8 l Z�— 1 T L
I am not using any subcontractors: ZA. T/G
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
.;� TEMP POWER
lCUPEkTINO PERMIT APPLICATION FORM
APN # 3 5,G o t 053 Date: q'Z F(�
Building Address: 2z 54 I jZ,cw J
Owner's Name: Phone #:
0'z-�6.w (yo7 ) % '19 -38y8
Contractor: A Ivan�—1 Phone:( License#:
4o8) $y9-SBy8 G I025�
Contact: [>an o« Phone: hyo 8 j g Nrr-S o 3S Cupertino Business License#:
Building Permit Info:
Elect ❑
Job Description: e Fiewc� polo f4c new
Residential Commercial ❑
Cost of Project: 30�
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
/ EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING