03050141 CITY OF CUPERTINO '.''' . '"
BUILDING DIVISION PERMITCON.,e'PRe� OR IIv' ,,sRMAT�IQN.
BUILDING ADDRESS: _ AHMAD SALEHI/SOGHRA MOGHAD N003050141
r 1 OWNER'SNAME: PmiMITLSkJpB/2003
HE: SANITARY NO. CONTROL NO.
ARCHITECnENGINEER: BUILDING PERMIT INFO
BLDGO ELECT O PLUMB MFICH
O O
a 0 z LICENSED CONTRACTOR'S DECLARATION lobDescri Description
1 hereby affimn Nn 1 am licensed under provisions of Chapter 9(commencing p
A� wild Section 7000)of Division 3.&M.Deal..and Professions Codednd my license is
In fLhcLicenea . effect. UPDATE CIRCUIT BREAKER
LZ Oamnse Clus Contractor
ARCHITECTS DECLARATION
I undermand my plans Mail be used as public excerds JUN 1 n �aAA
o l- D Ud
aO3
Licensed PN(CI4oMI
Oat I am exempt
from
DECLARATION
4 y 1 memo .Rens on 11. exempt(rose tins Doalaeloos :Any c law rte my `, R�
i 2 o following mason.(Saito 703 1.5, .man, and Profeaciau Cade:Any oily or County U'L®6
S$ which mquira n permit ro combust,alter,improve,h permit t m mash nY mmmum I'Y]A�P
Z i that he its mauxalicenced
e,aluantso to tes,hovisio s of for sucConnector's
.Lie s Law(Chapter
< (comms canuJ puruans to the provisions of theche Business,
uacwr.Lkcnselaw(C Code)
Sq.Ft. Floor Area �`1�bgflOn
,x❑� thammcne
(commencing it urefa rn and of Division sifr of Me al eg ed exempt Preon.Any
CMn)m
3$ Nn he is exempt Omre(mm and the Dub far Jn alleged exemption.Any vlolad'on of
Section 7031.5 by arty applicant for a pem it subjects Ne applicant to a civil penalty of 3 M3+ M 3Ber 0 0 Occupancy Type
Iwo mom Nan Ow hundred dollars($500). _
❑Lu worof Ne Penructamyomntendea wild offered
ste'v(Sec.
044,Hu meas
will do dm work.end the he Cst is nm,Liens oraatw doe Imcole(See.]044,Business
dna eny wh bar code:The.Mecwr.License law assn nal apply ti an owner of
is 5 01 — FINAL n�NERGY
progeny who wIIW or improves Ncman,and who tlas anhwoh Instruction through his
own employees,provided thmade,Improvements am not intended metered formals,If. 505 — FINAL ELECTRICAL
however,Ne wilding or improvement is sold within one year of completion,the owvcr-
bullder will have the burden of proving that he did not Mid or improve for purpose of
salt.).
Q I,as owner of the property,am euluively contracting with licensed connectors to
Conswct the project(Sec.7044,Business and Profetriom Code:)The Conuseuu's Li.
µe�w doss not apply to in owner of property who wilds or Improve thcmon.and,
W obsess forsuch pmJgTiarhlRrnn semrtn licensed Panama,w Ne eonuanara
W nu law.
l am exempt on Bee
BA
PC(oN
s Was, WORKER'S COMPENSATION DDatm
as A
o1herebyaEnunlowing
declarations: ,
1 haveend will meinWn•CardfamofCon entto self-insuroforWoraeraCompen-
mation,as provided fur by Seel.3700.1'the labor Code,for the performance of the
work for which this permit is issued.
❑1 ban and will mainufn Wukeh Compensation Inmlrvmc,u required by Section
3700 of NC labor Code.for dm performance of Ne work for which this Permit is issued.
My Workers Compensation Weaana carrier and Policy number am:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed lithe permit Isforone hundred dollam($100)
or less.)
I certify the,in to Perform work far hich Nis mnl0 b issued,l shall not
creployany�c rsenlnny mnnrap u to asubjmi to Ne Workeri Compensstion
Laws a(L�Jjrd)Olii Dam A
APp3c ri - 2�
N CE TO APPLICANT. L sff
Ier making this Certificate of Exemption,you Mould
e ubjem to dem Worker.Cma,munmr,provisions of Nc labor Code,you us,
Owith comply with such provisions or Nis Permit Mail be deemed ranked. -
'Z "' CONSTRUCTION LENDINGAGENCY
H 4 IMmby affirm that there is comuumion lending agency for Ne Performance of
C > the work for which Nb Permit B Issued(Sce,3097,Civ.C.)
QLenders Name
Z)z Lembes Address
U 0 1 certify Nat I have read dos application and sum that the above Ioformadun u
D.F comm I agree 70 comply with all city and county nationaa and sum lawn minting to
0V building conslmlion,nd hereby suNnria represematiws of this city to enter upon Ne
{fl abovo-memiramd Property for WIMC6011 Purposes.
y cs,ju agree la cove,indemnify and keep harmless the y se ofCupertinos id City
y Iiabllltl(We)grents,costsoan,and expenses nd keep
harmless
any twyty ofCagalnsno against
City
U z in consequenceof Nc granting ofi�/�
Nis emit. 71�h
APPLICANT UNDE AN 777NNNILL COMPLY WITH ALL NON-POINT Issued by: Date
SPUIjCE REGUTAA`NNS. / 4/
�Q �.1 -� z[ Re-roofs
kSignmum 01 AppEanV nusclor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicator or future wilding occupant mom or handle huWons material
as dc0nd by the Copenin Muo'ipal Code.Chapter 9.12,and the limits and Safety
Seld❑Yes Nuen zss255324)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hDanics" air ConlaminanY aNcfned by Ne Bay,Arte Air Quallly Memgcmenl all new materials for inspection.
❑Ya No
I have mad are baurdouememriab Iemlmervartsunde,Ompmr6.95 of Ne Califor-
ria HmlldhSafetyCade,Sectimu23X15.25533 and 25534.1 mWcuund Jm irtle wilding L/�I /yam
does nal currently haa, t y res uiinlilY aoufy am occupul of Nc /Y / O C� 3
quiremmets with, beme,P' issuance a maromparaq Signature of Applicant Date
12!k ' All roof coverings to be Class "B"or better
wner sir ev,horixed agent Bate
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
• 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse si%d
Property Owner's Signature e�S ✓� D.W SAy J
L O � a
r
Job AddressPermit z
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF CUPERTINO
CUPEYOF PERMIT APPLICATION FORM
a.
N# --1 ^ Date: 5./ Z r/ o 3
Building Address:
i v
ress: M S 1 Com- W (/
d l
Owner's Name: 07 vA 1 nn Phone#:
A Met() Sale A n
Contract�or� r� �G License #: t/ ,
Contact: Q(f/A Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect._ Plumb ❑ Mech ❑
Job Descri d_o_}• KefL �,,
Residential r - Co ercia '0/' r / �/
Sq.Ft. Floor Ar $/ q. t.:
Cost of Pr Iect: , O O Occupan ,0,U .
Type ofn tru tion
Ad Ilk
L ;c� �z G ►,� kir
Quantity, Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler>. 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/OfflComm/ uasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V<= 1000A ELECTRICAL
Ok BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. HousingMit, Fee BUILDING
P-' 2V �� 7
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�
alTYMOM
CITY OF CUPERTINO
PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING.
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rirMerBackflo PLUMBING
BPSTORM Stonn/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfin MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREM 3USWAY Remodel Busways ELECTRICAL
BREMFD{T Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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CITY OF CUPERTINO `y
acloF PERMIT APPLICATION FORM
CUPEkTINO
Quantity .Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
-BREMRECEPT Rc tl, Switch& Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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