B-2016-3241 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3241
10204 BRET AVE CUPERTINO,CA 95014-3558(375 11 034) THD AT-HOME
SERVICES INC
ATLANTA,GA 30339
OWNER'S NAME: YAVARI KHASHAYAR AND SARA TRUSTEE DATE ISSUED:12/09/2016
OWNER'S PHONE:408-499-7098 PHONE NO:(770)779-1423
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B:C-39:C-13:C-17 Lic.#836021
Contractor THD AT-HOME SERVICES INC Date 04/30/2018 X BLDG _ELECT _PLUMB
—MECH X RESIDENTIAL_COMMERCIAL
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. JOB DESCRIPTION:
INSTALL BLOW IN INSULATION(938 S.F.)-ATTIC
I hereby affirm under penalty of perjury one of the following two declarations: .
i. 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
have and willof themaintaworkWfor whichorker'sCthioms permitenation is issuedInsurance.
,ase1zperformance
, Iinp 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:$1443.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 375 11 034
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Se" n 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 12/9/2016 Issued by:AbbyAyende
c- Date:12/09/2016
I iiJ5lt-: II i t t . 1", t:: i.
I hereby affirm that I a,"' empt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofmg material being installed.If a roof is
i. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:12/9/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505 25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. y,.Owner or authorized agent:
APPLICANT CERTIFICATION Date:12/9/2016
certify that I have read this application and state that the above information is s -TR s�Il_ J!1 N
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a cg *motion lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-pointsource regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Signature Date 12/9/2016 Licensed
Si
9 Professional
p),_101.(0- 'Z I
B
,\\,I J// CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildinq ac cupertino.orq
CUPERTINO
NEW CONSTRUCTION El ADDITION El ALTERATION I TI ❑ REVISION I DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS/ ,••• -16.- i
OWNER NAME
PHONEE-MAIL- v5l (dyl� 9 Arg-t
STREET ADDRESS r.. CITY,STAlTE,ZIP g�y
l 0'2.c) i Z i ,/1-J L C c PL-42-7I4O r C Scl r 7
CONTACT NAME JEFF RAINEY PHONE 510-427-4260 EMAILJEFFREY.RAINEY@ATT.NET
STREET ADDRESS 1069 EDGEMERE LANE CITY,STATE,ZIP HAYWARD, CA 94545 FAX 510-783-1041
❑OWNER 0 OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR ti CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CONTRACTOR NAME
f LICENSE NUMBERLICENSE TYPE BUS.LIC# .8 1 Z
836021 ( B,C39,C13,C17 2_01 1
COMPANY NAME E-MAIL FAX
THD AT HOME SERVICES 510-357-3750
STREET ADDRESS CITY,STATE,ZIP PHONE
2456 VERNA COURT SAN LEANDRO,CA 94577 510-877-4550
ARCIHTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME I E-MAILFAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OFWORK IA
S.5 -t r �- L ....., f� ,/`I 1 7Xe / 'li-7w ) - /0
EXISTING USE PROPOSED USE CONSTR TYPE #STORIES - - _
USE TYPE OCC. SQ.FT. VALUATION($)
EXiSTG NEW FLOOR DEMO TOTAL.
AREA. AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: 0 DETACH
0 ATTACH
if DWELLING UNITS: I ISA SECOND UNIT ❑YES SECOND STORY - ❑YESI - - -
ANG ADDED? U NO ZDITION? '❑NO I
I
PRE-APPLICATION DYES IF YES,PROVIDE COPY OF IS 1'HN,BLDG AN ❑YES I2Et' E[J, 'Y` ,_ TAL VALUATION3:
PLANNING APPL# ❑NO PLANNING APPROVAL LE ITER EICHLER HOME. 0 NO s', eL
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Wo d-veni`y it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize represen,::'v o Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: l 2-1 ` f J do
SUPPLEMENTAL TAL INFORMAT s
RED
New SFD or Multifamily dwellings: e�, or demolition permit for fy
existingbuilding(s). Demolition ermi, required prior to issuance of buildingpv x ,liooc xli�lTElt Btr I :n.,:,is r#E o x
permit for new building. ] [ 1��I1ItAN JiRt
Commercial Bldgs: Provide a completed Hazardous Materials Disclosuret i f (3 ,iB � .
form if any Hazardous Materials are being used as part of this project.
AAI�G�' �00001i1
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. Ld� � !
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BldgApp_2011.doc revised 06/21/11