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CITY OF CUPERTINO
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BUILDING DIVISION -- -
'PERMIT
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BUILDING ADDRESS:
PERMIT N® 4 12 0 0 94
0902 HANFORD
OWNER'S NAME: -
-
PERMIT ISSUE DATE
HARISH AGASTYA
2004
NE:
SANITARYNO:---- -'--'CONTROL NO.
'ARCHITEC (ENGINEER:
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BUILDING PERMIT INFO
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BLOG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTORS D LARATION -
I hereby affirm Nat 1 am focused under p cions of Chapuir 9 (commending
- Job De$CEIpt100
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70M) of Division 3 close HU -1 dl roRssmns Code, and my liceve is
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Ietron
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6S G
TEMPORARY POWER PERMIT
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Date C 'Cori
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AR ITECTS DECLAR N
I understand my plans s all Ine u'se7�d as public records
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Licensed Professional -r,`
OWNER -BUILDER DECLARATION
-
1 hereby affirm Nal 1 am exempt from me Contreetro's Lima. Law for the
following reason. (Section 11131.5, Business and Professions Code: Any city or county
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which inquires a permit to construct, alter, improve, demolish, or repair any structure
S500
- Sq. Ft. Floor Area
.. Valuation
prior m its issuance, also requires the applicant rorsuch permit ro file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing wish Section 7") of Division J of the Business and Professions Code)or
.
Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 2jkWN&rTejD 0
_ Oe pan y Type
Section 103 L5 by any applicant for a permit subjects the applicant to a civil penalty of
netmou Nan five hundred delta. (MOO).
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❑ Las the property, m my cmntendes wage u
(Sm.
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... �-... ;=Required Inspections . .:`M• v ,Jr�. '
a work. ale 7044. Business
will domcwons end Use noti License offered
Comcture orhien.owmar
Contncmrs Liceme Law encs
of
and Professions coda. The pactor's not apply m an ownu of
The s not apply
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Ownenywhobuddsandthatssthimprovndwhodoessudtendework hsmulfmNroughh
Ntow
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e
however. Usecsldingor imprpueont issementssnom yetendedmoRered
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yea( of completion, theos c-
omm� of pmentaa solde did
however. the have
builder will have Ne burden of proving met h<did not build or improve for purpose of
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sathJ:
1, es owner of the property, am exclusively contacting with licensed contractors to,
construct the project (Sec ]Oda, Business and Professions Code) The Contractors L
([(J�,%
`nz
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c tee law dors not apply to an owner of property who builds or improves thereon d
who contracts for such projects with a contaacter(s) licensed pursuant in the Contractor's
License Law. -
I am exempt under Sec - .B&P C for this reaso.,
Owner Data
WORKER'S COMPENSATION DECLARATION''
1 hemby affirm under penalty of penury one of Ne following da[amions:-
IhawandwillmaiuMinaCeniricamofConsemmulf-insumfor Wader's Compcn-
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atlon, u provided for by Section ]100 of me labor Code, fat me peranammee of the
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work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, sa requited by Section
- -- '
1100 ofthe Code. walk forwhichathis permit is issued.
nsatifor nmsuranceperformance and
mixers Compensation Insurance carrier and Policy number arc:
rs Co
'er.iuwli�Po1'avn};y.2Si
C TIFlCA OF. EMPf10N—M -WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is reran hundred dollam(SIM)to
]uss.)
,
1 certify Nat in the performance of the work for which Nis permit is issued, I shall not
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employ any Notion in any manncfsn as to become subject 10 the Workers' Compensation
-
LawsofCaliromia.Da¢
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Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation previsions of the Labor Code, you mon
forthwith comply with such prnvisions or this permit shall M deemed mvoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm, Nat there is a construction lending agency for the performan e, of
the work for which this permit is issued (Sec. 3091, Civ. C.)
Lendces Name
tender's Address
I certify Nat 1 have read this application and stat, mat the above information is
.
correct. 1 agree to comply with all city and county ordinances and sate laws plating to
building construction. and hereby auNorrre representatives of Nis city ro enter upon the
abovvmemiuned propeny for inapecuun purposes.
(We) agree to save, indemnify and keep harmless Ne City of Cupertino against
Iiabiliues,judgmena.mew, and expenses which may in any way accmc against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type Of Roof
_ "
Si aturcof ppicantiConuactor -- Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle havudous material
as defined by the Cupertino u icipal Code, Chapter 9, 12. and the Health and Safety
Code, Section 25532(a)? i
All roofs shall be inspected prior to any roofing material being installed.
Ys
'ding
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant r fuwre occupant tau equipment or devices which
.rat be,afdnua so- conmminanu , recd by the Bay Area Air Quality Management
all new materials for inspection.
Disvict?
❑ Yes
I havc mad me hax Ousmateria quimmcn¢underChapwr6.95oftheCaliber-
maHealth&Safely Code ccuuru 25W5,255JJ and 25534.1 understand mat if the Wilding
s not eunendy havc a tenan4 Nm it is my responsibility m nndly the occupant lir the
gaimmenrs wMm must be ma psiur to isspan,e,ra c,rdB, to of0mapancy.
Signature of Applicant Date
�"-.d.�y�er`tS�cq
All roof coverings to be Class "B" or better
Owner
tar authori cJ agent Doc
al
CITY of
UPEkTINO
CITY OF CUPERTINO�
TEMP POWER
PERMIT APPLICATION FORM l 0
APN #
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EPERMITFEE
Date:
ELECTRICAL
BUSLIC
Business License
BUILDING
Building Address:
1/-C� `I o 2
H A -N -PO Rj) R• CQ
PC-, TI -0 CP\
Owner's Name:Phone
S',
AGAs7 A
#:
4og
666 2-747 .
Contractor: Phone:
License #:
N&.1RY 'j-RA-nI
Contact:
Phone:
Cupertino Business Licehse #:
Building rmit Info:
1
Elec
-145
Job escri 'on:
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Residential ❑
I Com ercial ❑
Cost of Project:
i
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Qtyic lYfe Fee ID
Fee Description
Fee GrouD
BTEMP
Temporary Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance -
ELECTRICAL
BUSLIC
Business License
BUILDING
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