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10020069 CITY OF CUPERTINO BUILDING PERMIT 'BUILDING ADDRESS: 18791 LOREE AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10020069 DATE ISSUED:02/12/2010 OWNER'S NAME: BEHDAD JAFARI PHONE NO: IER'S PHONE: 4086561139 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r License Class Lic.# MECH F RESIDENTIAL r— COMMERCIAL F Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 TOB DESCRIPTION:UPGRADE ELECTRICAL PANEL FROM CURRENT 30AMPS O (commencing with Section 7000)of Division 3 of the Business&Professions 200 AMPS 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. I 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 Sq.Ft Floor Area: Valuation:$500 permit is issued. APPLICANT CERTIFICATION APN Number:37513019.00 Occupancy Type: 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 upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. a Issued by� Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Date: Business&Professions Code) Signature of Applicant: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 1 have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I mus Owner or ?oNS a Date: 2 Z (•� forthwith comply with such provisions or this permit shall be deemed revoked. TRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating; for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save -nnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address and expenses which may accrue against said City in consequence of the gi—Ming of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the upertmo Municipal Code,Section 9.18. T I understand my plans shall be used as public records. Signature Date 2 Z Zo(O Licensed Professional � �, CITY OF CUPERTINO CUPS Of GENERAL BUILDING APPLICATION FORM � � we PERMIT A .C _.� Date: APN # . „� J 0`C� Building Address: �r Mailing Address (if different from buil ding address): q 5-<>7o Are Hazardous Materials being used as part of this project? Yes No ] �If ves, provide letter from HOA HOA: Exterior work onl Yes ❑ No phone#: . Owner's Name: J 1 � 'e Contractor: Ph u)v, one: 6 50--M-75-74 ,kl , pv , E le't-,fit c Fax: Contractor License#: 3 7S q 9 1�- Cupertino Business License#: phone: Contact: J�J� �`�� `'SAL&8 i Fax: Residential Commercial ❑ Job Description: f 0!0'-c GSA t,6 15 I Building Permit Info: Elect L'�J Plumb ❑ Mech El Bld ❑ Occupancy Type: Type of Construction(Usage Class): IUIII B, IV-HT,V-B II/III/V-A 1-A, 1-B ❑ ❑ Square Footage: Valuation: SpG Project Size: Express andard ❑ Largf:❑ Major ❑ Green Building: Please complete relevant portion of the Green Builth & the sheet endext& attach it to the application or if applicable, include m p Points Achieved: For help, contact Build it Green at www.buildity reen.or Revised 07/14/09 { CITY OF C'UPERTINO Cin OF GENERAL BUILD[NG APPLICATION CUPE(�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Al plications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea ,3 windows) 1WINMEWSTR New Win iow-structural shear B wall/masonry (includes plan ck fee) IEPERMITFEE Electrical=Permit:Fee:: E 1 MPERMITFEE Mechanical Permit Fee M IPPERMITFEE Plumbing;Permit Fee P 1 ELCPLNCK Stand Al ane Electric Pln Ck (hourly) E IJMECPLNCK Stand Alone Mechanical PIn Ck(hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/ P) B when not over counter) hourly-stand alone / 1BCBSC Cal Bld;; Standards Commission Fee B ALL EPRMIT r 1BSEISMICR Seismic Residential ESB 1BSEISMICO Seismic Commercial B ITRAVDOC Travel ,9-, Documentation B 1BUSLIC Busine:;s License B v G I 5 of 5 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37513019. 00 DATE ISSUED. . . . . . . : 02/12/2010 RECEIPT # . . . . . . . . . BS000009740 REFERENCE ID # . . . : 10020069 SITE ADDRESS 18791 LOREE AVE SUBDIVISION . . . . . . . CITY CUFERTINO IMPACT AREA . . . . . . OWNER BEF-.DAD JAFARI ADDRESS 18-,91 LOREE AVE CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM BEEDAD JAFARI CONTRACTOR TBI> - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBI) - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- - ------ ---------- 1BCBSC VALUATION 500 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 500 .00 0 . 50 0 . 00 0 .50 0 . 00 1EPERMITFE FLAT RATE 1 .00 42 . 00 0 . 00 42 . 00 0 . 00 1ERT<200 UNITS 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0_00 ----- ------ TOTAL PERMIT 127 . 50 0 .00 127 . 50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ----------- CREDIT CARD 127 .50 MC --------------- TOTAL RECEIPT 127 .50