10030124 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1330 FLOWER CT CONTRACTOR:SAFA CONSTRUCTION PERMIT NO: 10030124
COMPANY
OWNER'S NAME: KOUROS SANJIDEH 13641 FERNCREST CT DATE ISSUED:03/19/2010
NNER'S PHONE: 4082578725 SARATOGA,CA 95070 PHONE NO:(408)209-6060
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class Lic.#�� � INSTALLATION OF NEW TANKLESS WATER HEATER
Contractor
I hereby affirm that I am licensed under the provisions of Chapt r 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:36618038.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regul 'ons per the Cupertino Municipal Code,Section
9.18.
Signature Date RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
OWNER-BUILDER DECLARATION inspection.
hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Mu 'cipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,2553 nd 25534.
Section 3700 of the Labor Code,for the performance of the work for which this '1)
permit is issued. Owner or authorized agent: Date:
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
anon the above mentioned property for inspection purposes.(We)agree to save
emnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
.,sts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all Le
int source regulati s per the Cupertino Municipal Code,Section Licensed Professional
9.18. (�
Signatu Date l �d
CITY OF CUPERTINO
WATER HEATER
CUPERTINO PERMIT APPLICATION FORM
(Da
APN # Date:
�U Ma SCh - I
Building Address:
1330 r-Lc-)w"- Gout"
Owner's Name: Phone
90vfoS So yl J
Contractor: Phone #: 4 px-2-n -Leo&p
S}STA Co rV ST►2 UG-T l dn) Fax #: 4C)3-34-']-499
Cupertino Business License #: 2 9 Z 14_ Contractor State License #:
Contact: SNI Ot►1�Vl D 0 S a T Phone #: 4-pg.ZQ q-6 D,6 D
Fax #: 408-34q-I�Lq 9
Building Permit Info:
Bldg ❑ Electl Plumb Mech E5--
Residential [011"' Commercial ❑
Job Description: 'hs�gl(A`C�
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement
Valuation (cost of project): *P,CC\'
Project Size: Express rT Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, include in plan set & the sheet index.
Green Building Points achieved:
Revised 03/10/10
CITY OF CUPERTINO
WATER HEATER
COF
CUPETRiNO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCWI-EATR Commercial Water B PCWHEATR
HeaterNent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
IBSEISMICOM Seismic Commercial B
1PCSWHTR Commercial Solar B PCSWHTR
Thermal Water Htr
1 PRWHEATR Residential Water B PRWHEATR
HeaterNent
1PRSWHTR Residential Solar B PRSWHTR
Thermal Water Htr
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
l Commission Fee
1BSEISMICRE Seismic Residential B
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel & B
Documentation
1BUSLIC Business License B