06100172 CITY OF CUPERTINO
BiJILDING Vi VISION PERMIT +G T ACTOR N C}RMATIQN
BUILDING ADDRESS: SIL ICON VALLEY PLUMBING PERMIT NO-06100172
18654 LOREE AVE
PERMIT ISSUE DATE
OWNER'S NAME:
RAMIN GOUDARZI 287 SAN JOSE AVE 10/23Z2006
SANITARY NO. CONTROL NO.
INE:
(408) 292-3975
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
!0 p LICENSED CONTRACTOR'S DECLARATION Job Description
U r 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
?z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
>>y in full force and effect� Lu * 511 REPLACE WATER SERVICE
j ? License Cl
f in Date AL Contractor
ARCHITECT'S DECLA ATION
,a
U 1 understand my plans shall be used as public records
O
H Licensed Professional
H OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct.alter,improve,demolish,or repair any structure
u Z y prior to its issuance,also requires the applicant for such permit to rile a signed statementValuation
_ that he is licensed pursuant to the
Sq.provisions of the Contractor's License Law(Chapter 9 Ft.Floor Area
$1900
F- (commencingwith Section 7000 of Division 3 of the Business and Professions Code)or
L that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
❑I,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.7004,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such pmjects with a contractor(s)licensed pursuant to the Contractor's
License Law.
C]I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,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 required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of c wo c for which this permit is issued,1 shall not
employ any person in any mann q&VjpttgWc subject to the Workers'Compensation
Laws of Cal' ia.Date
Applicant
NOTICE TOVPPLICANT.If,after making this crificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
(~-t►N.r I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W ALender's Name
a z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LL ►. correct.I agree to comply with all city and county ordinances and state laws relating to
rJ- Ubuilding construction,and hereby authorize representatives of this city to enter upon the
Wabove-mentioned property for inspection purposes.
O (We)agree to save,indemnify and keep harmless the City of Cupertino against
V2 liabilities,judgments,costs and expenses which may in any way accrue against said City �7 /,
U Z in consequence of the granting of This mint. Date
►' APPLICANT UNDE TANDS AN WILL COMPLY WITH ALL ON OINT Issued by: U�
SOURCE LATI NS.
o Re-roofs
Signature dApplicanitoRractor NJtc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant.store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
E]Yes fSN°
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
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes
1 have read the hazardo�us)materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cole.Sections 25505 5533 and 25534.1 understand at trthc uilding
7.
does not c ntly ha a tenane at it my responsibility in
notify th occup t of the
requircrien icn st be me rior issuance of a Certificate of tic pantry. Signature of Applicant Date
Owner or tnorired ent d All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
MY OF Fax(408)777-3333
'WEkTINO
Building Department
JOB ADDRESS-. PERMIT #
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
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
Tilq
Owner/C6ntractor Signature Date
CITY OF CUPERTINO
m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN 37525069 . 00
DATE ISSUED. . . . . . . : 10/23/2006
RECEIPT # . . . . . . . . . : 36538
REFERENCE ID # . . . : 06100172
SITE ADDRESS . . . . . : 18654 LOREE AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RAMIN GOUDARZI
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : SILICON VALLEY PLUMB
CONTRACTOR . . . . . . . : ROBERT SANTOS LIC # 25993
COMPANY SILICON VALLEY PLUMBING
ADDRESS 287 SAN JOSE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408) 292-3975
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - -- - - - -- - - ---- ---- - --- -- ----- --- - --------- ---- - ----- ---------- ----- -----
BPWSVCS WATER SERVICE 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
BUSLIC FLAT RATE 1 . 00 105 . 00 0 . 00 105 . 00 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
- --------- ------- --- ---------- ----------
TOTAL PERMIT 152 . 37 0 . 00 152 . 37 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - -- - - - ---- - ---- - ------ ------ ------------------
CHECK 152 . 37 1462
TOTAL RECEIPT 152 . 37
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 106 SEWER & WATER
507 FINAL PLUMBING
CITY OF CUPERTINO
REPIPE/S WE. .S/MAIN SERVICE
CUPNEkTINO PERMIT APPLICATION FORM
APN # D a�te/
In
Building Addre s:
v
01�
Owner's N e: �� /� Phone#:
Ctractor: i (,D one: License #:
CZo �N`lnq06 8-2+9' QT i
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: "-YLI
Residential Commercial ❑
Cost of Project: " �49t7
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING