05060096 (2) CITY OF CUPERTINO '�t6
BUILDING DIVISION PER aCON�TRAC ORjNFOR IONS
BUILDING ADDRESS: (TACK MYERS CONSTRUCTION PERMIT"°05060096
11411 BUBB RT)
OWNER'S NAME: PERMIT ISSUE DATE
TAHSEEN ADEEB 1965 COLLEE
SANITARY NO. CONTROL N0.
(408) 761-1185
ARCHITECf/ENGINEER:
BUILDING PERMIT INFO
' BLDG ELECT PLUMB MECH
0 I� 0
j00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
wp 1 youth,affirm Thal I am licensed under provisions of Chapter 9(cco mating p
iW with Section70(10)of Division 3 of the Business and Profeztions Code.and my licenscu
6
in mu tnrecaodeffccl. REMODEL MS BATH
�? Licnlac Cons Lica
F Da¢ Conusewr
ARCHITECT'S DECLARATION
1 understand my plans shall he used as public rands
to
cu
G� Licensed Pnfestienal
3 OWNER-BUILDER DECLARATION
t f I hereby air.,ho,l son exempt oaet
ept form de Conoe.U,cnse Law ro,the
00 following mason.(s edon 71131.5.Business and Profession Code:Any city of courtly
which requires a permit to conarnn,eller.Uniform,demolish,Or repair any structure
zi prior in its issuance.also mqunes the applicant for such pcimiuo rile a signed summon
i< that heulicensed pursuan.toMeinwiti...flWContractor.U ..Law(C7npmr9 Sq.Ft.Floor Area Valuation
t-$ cn w
(commencing with section Division 3 of Oc Businand Professions Colt)
`L— Thal M u exempt Ocrefran and the Who for the alleged exemption.Any violation or
Section 70315 by my applicant,fora permit subjects Me aPplianl w a CIO penalty of er0 0 Occupancy Type
not mom Nan rite hundred dollars(S500).
❑1.n owner of Me property,or my employee with wage at their sole compensation,
will det Ne work,and the structure is not intended m offend for sale(Sec.7(44,Businiss
and Profession Code:The Con otwe,License law does not apply w in owner of Required Inions
,imperty who builds or improves thereon,and whodoessuch work himself or though his - -
uyn cmployse.provided Oat Men impromments art ata intended or offered for sal.If.
howem,Ne Wilding or improm eni is sold wi thin one,year of completion.the owner.
builder will have the WAen of proving Nat be did rot Wild or improw for purpose of
/ark.).
❑1,u owner of Ne propert,on uelusiml,contracting wish licensed conuacwrs to 3
consvuel the pfojcct(See 7044.Business and Professions Code:)The Contractors Li.
cense law don not apply to in owner of property who Wilds or impro ss themron,and
who contacts for Such projeeta with a cmaraewf(x)licensed pursuant to the Gnntrolnfa v
License Law.
❑Itina' �`/^ytunder Sec .B&P C for this reason
Owner �/�- Dam l .
WORKE COM NSAnON DECLARATION
1 hereby&Roto under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Concent to self-insure for Workers Compen.
stow..as provided for by Section 3700 of the Labor Cede.for the pedo..of the
wart for which this permit is isated.
❑1 have and will maintain Wakes Compensation Isswmnce,as recrossed by Section
3700 of Ince labor Code,for the performance cram work for whim out permt is issued.
My Workers Compensation Insurance arricr and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu soctioo need not W completed lithe permit Is forme hundred dollars(SIM)
or lea)
1 cenify Nm in the performance of Ne work for which this permit Is issued,1 shall not
employ any,emon in any manner so o em sec 'ccuo the Worked CompMaMon
Laws of California.Da
Applicant I
NOTICE TO APPLICANT:If,after making this Ccniriate o Exemption,you shouw
bccomc subjm w the Worker's Compensation prevision of the Upon Cods,you muse
Z roMwith comply with inch provision or this permit Mail be deemed rooked.
0
1 CONSTRUCTION LENDING AGENCY
I for
whalarm than drert is s c d(Sec.nn lending agency(nr Nc perfurmamx of
i the work fur which this pcnnil is issued(Sec.3097,Civ.C.)
1 A Innd e:Add
)Z 4ndcAddnss
0 1 certify that 1 haw read this application and sum that the aWm information is
rco.I agmen u comply with all city and county ordinances and sum laws¢Ming to
j U
Wilding construction,and hereby authorin repnsew ton atims of this city enter upon
r ahow-mentioned pmpery for inspection purposes.
6 (Ws,)agree to an.indemnify and keep harmless the City of Cupertino against
fA Iiubilitics,judgmcnts,costs and expense which may in any way accorc against old City
Z in consequence of she granting of this permit
APPLICANT UNDER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOIytCE REGULATI
y t lla 6111�b� Re-roofs
Signature nrnpplicah ontraclor Dir
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or fumm building acupanroom or handl,haeardous material
n defined by the Cupertino Municipal Cock.Chapter 9.R and Me Health and Safety
Code.Sccdon 2553I(a)7
❑Ya )6 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding azupanl no re utpmcot or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil hanrdon air smuminants ar defined by Ne Bay Am.Air Quality Management all new materials for inspection.
Dieolct7
❑Ycs KN.
1 have nod the hnurdousmaterials mquimmenu under Chapmr 6.95 of the Caliror-
niaHealth&Safely Colc.Sec1JOssn 05.U533 ara125534.1 un&tsrand witifthe Wilding
does.1 currently hoe•team,Nu it u my woomMilh,u notify We occupant of Ne
�ts mhmuslWmet hour;Kor.CirurtateofOccupancy. Signature of Applicant Date
L All roof coverings to be Class"B"or better
Owner m authofivcd&gum-: Dom
an CITY OF CUPERTIN� _ D (� `
o a �6
CITY OF PERMIT APPLICATION FORM
® CUPERTINO
APN# X35 23 - 049 Date:
Building Address: /� Mailing Address (if different from building address):
//.4// & � t kooj YA'^jD CFIn95-019
Owner's Name: Phone#:
c� 3cC71 �DC-& 120g- $2�Q- ?82�
Contractor: License#:
-JA-e/< Myc- Pg - 634- D66
Contact: Phone: 40S-ZM--?S 2-9 Cupertino Business License#:
/ R.?C-c-no 4b Cc a Fax:
Building Permit Info: kemLode_,
Bldg ® Elect M Plumb Mech ❑
Job Description: a8 r esl�o„
Residential k M"J,f 8aAyv0JV` Commercial ❑
Sq.Ft. Floor Area: /2 x /0 8 n / 30 4�j.�G $/Sq.Ft.:
Cost of Project: Occupancy Group:
/or 0 o0
Type of Constructio : Please check this box if the project is a
��ehlOCIel • roona second-story addition: ❑
Project Size: Standard Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
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/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee f BUILDING
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CITY OF CUPERTINO
CITY Of PERMIT APPLICATION FORM
CUPEI.TINO
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
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 rinklerBackflo PLUMBING
BPSTORM Storm/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 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l 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
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
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.. fTY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, 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
3 h ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
30 PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi4am PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
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CUPEfZTINO
Assessor's Parcel Number: 3 S (o - 2 ?,
Name of owner. I AHStCr 5 AND FAREEDA
Project address. 11411 (Z->L) l3 P, ROAN CUPERTII\)o CA 95DI if
Contact person. I A HSC E N ADE&P, Phone. 4o S - .229 - �7 8 2 q
Fax. 40
Net square footage of lot. 2 4 9 2
Existing Proposed
Square footage: First floor: I &I 2
Second floor: 1 0 0 0 I OOy
Garage: 6-20
TOTAL: 3 O 1 2
® Are there at least two 10 foot by 20 foot clear spaces inside the garage? OY N
Is privacy protection planting required for the project? Y NO
On what floor(s) is work being done? 6C-CO"I>
Brief description of work. RPQ7tAn4o N1mh, b mQn-) balh on�jc�ir�a
0, i c,l.O :h2 a-I�e h�a roaYn
Code editions: 2001 CBC (Y -N)2001 CFC (Y -N)2001 CMC (Y-N)
1001 CPC (Y -N)2001 NEC (Y -N)
Effective 11/1/02
Plan Review Process Work Book Page-8-Revised 5/3/05