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10040048 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22757 STEVENS CREEK BLVD CONTRACTOR:BAGHDASARIAN SYLVIA PERMIT NO: 10040048 AND VAROUJ NER'S NAME: BAGHDASARIAN SYLVIA AND VAROUJ 22757 STEVENS CREEK BLVD DATE ISSUED:04/07/2010 OWNER'S PHONE: 4084065678 CUPERTINO CA,CA 95014-5628 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r License Class Lic.# r MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION:ELECT MTR RLS**INSPECTS DONE ON#10020006** I hereby affirm that I am licensed under the provisions of Chapter 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:$100 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 permit is issued. APN Number:34212028.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued b} - Date:�i 7-� 9.18. S' •,tture Date RE-ROOFS: OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 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 Owner o•authojize agent: /J Compensation laws of California. If,after making this certificate of exemption,I ` c- Date:__/ become subject to the Worker's Compensation provisions of the Labor Code,I must V ` forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address the above mentioned property for inspection purposes.(We)agree to save anify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. _ Licensed Professional Signature V -V' Date 2--YV CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34212028 . 00 DATE ISSUED. . . . . . . : 04/07/2010 RECEIPT # . . . . . . . . . BS000010125 REFERENCE ID # 10040048 SITE ADDRESS 22757 STEVENS CREEK BLVD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER BAGHDASARIAN SYLVIA AND VAROUJ ADDRESS 22757 STEVENS CREEK BLVD CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5628 RECEIVED FROM VAROUJ G BAGHDASARI CONTRACTOR LIC # *OWNER* COMPANY BAGHDASARIAN SYLVIA AND VAROUJ ADDRESS 22757 STEVENS CREEK BLVD CITY/STATE/ZIP CUPERTINO CA, CA 95014-5628 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- - 1BCBSC VALUATION 100 .00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 100 . 00 0 .50 0 . 00 0 .50 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 - ---42 . 00 ----- - - 0_00 ---------- ---------- TOTAL PERMIT 43 . 50 0 .00 43 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 43 . 50 VISA --------------- TOTAL RECEIPT 43 .50 i CITY OF CU PERTINO CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM -J Date: APN#� � t A U �f G� Building Address: �� l Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work onlyYes ❑ No a f Yes, provide letter from HOA Owne 's Name: Phone#: Contractor: Phone: Fax: Contractor License#: Cupertino Business License#: Contact: Phone: Fax: Residential Commercial Job Description: Building Permit Info: Bldg ❑ Elect U Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B V -7 `3 Valuation: / � �� Square Footage: Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set & the sheet index. Points Achieved: ` For help, contact Build it Green at www.buflditgreen.org Revised 07/14/09 CITY OF CUPERTINO CITY OF GENERAL BUILDING APPLICATION CUPERTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B 5 of 5