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06060204
CITY OF CUPERTINO r ^`F.'atYa,s its<*' s x w'•m'+k a �"`°?`"`' '` ' BUILDING DIVISION PERMITCONTRACr' UItI1FC)ItMATId!N„ n},+Fsyy, �;a xw ,? whk3 ss, x`so+'^ age-ix B UILDINO ADDRESS: H POURABDOLLAH 1ERMITNO.0 6060204 18614 LOREE AVE ER'S NAME: PERMIT ISSUE DATE HAMID POURABDOLLAH 6 PHONE: SANITARY NO. CONTROL NO, ARCHIIECDENGINEER: BUILDING PERMITINFO BLDG ELECTPLUMB MECH t ::3 30, LICENSED CONTRACTOR'S DECLARATION lob DCSCrlpt100 mm d FFy I hereby affirm Nn 1 am licensed under pmvisiou of Casper 9(commercin(commercial;wiNS. TOM)of Division 3 of the Business and Professions Code,and my nce=is S It in full to=and effort. SERVICE UPGRADE TO 200 AMP gZ License Class / Lk.a Dow.Contractor 7 ndsand! parts DECLARATION < I uery ps l a used as public records U C/ / G Licensed Pmfeasional O3 OWNER-BUILDER DE CLARATIri Z 1 nam .(Sure that 1 1. wempn sem the Contrmar's Licenu Law for tic /1 p o fallowing moon.(Sadao construct. n 1.5, t.amps and Improve, Professions Code:Any city or semen l/ $ whleh,asrequires scrpermit recoruw0.elanimprove,ant h remit t firt le a Sigany swnum SOO —zi pat he issiensedpalso uantin res thaappe,aide Commminmccow Ladsawmcm pps`o dealncisficenseapnrwamwueproviaiaasafdKeonlracwral��trtl.w(Chapter e Sq.Ft.Floor Area Valuation Y k'$ (commencing with Section 70DO)of Division 3 mile Bualncssand Professions Code)or e S g that he N exempt L e rfsam and the basis for to alleged eaempdon.Any violaioet of Sea don 1031.draw Bbbyy b�aaRa ant far a permit r h subjects die applicant w a civil penally,of Occupancy Type ❑1,u own"of Ibe pmpmy,air my employma wW wags u then cele wmpenadon, willdothewark,andueswauretswtwmnded"afkmdf"We(Sa.70N.Butircu Required Inspections and Pmamas w retCade:The comewrs License Law daewwwa a t apply he nr of 4 P property who builds or im pro m a therwn,and who does such mark himself or Ihmugh h4 own employe",provided dutsueh Improvements me net intended arartered foraae.If. however.to building or Impmvemwl IS mid within con)ear of wmpleton.dta owwr- builder will have the burden of Poving that he did an,Wild or improve fm purpose of sale.). 1.u Owner of to Property am esclusively waeaing wide licensed cenua[wrs w wet dee pmjm(Sec.7014.Business and Pmfetamas Code:)The Conwcwrs Li- cense Law drew nut apply w w owner of property who builds air Improves thereon,and, who wntrmis far such projector with a cama wrens)Bound punctual w to Conuume. Lleeme Law. ❑lam uecmptt under Se—e� B A P C for this reason now WORKERS COMPENSATION DECLARATION I hereby,alRtm under penally of perjury raw of the following declarations: ❑thma illmainWaaCatiOwwof Cansentwulf-iwuefmWorkcesCmm- sW on,u provided for by Section 3700 of the Labor Code.for dee performance of the work far which this permh is issued. ❑I nava and will maintain worker.compensation Insurance,u required by Section . 3700 of dee Labor Code,fa the Forecasts aide work forwbich Nu p"mit is Issued. ' My Workers Compensation insurance canner and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This mire need not be completed Xnbe pamb is(wont hundrddo0aa($100) air was.) I certify that in to performance of the work for which this pam0 U Wood.I shell nm ..Play any person in nay masse(an�w brtomefubj�ntheworken'Compensation Laws of Califmona.Dames/``ll DD //�� Applicam NC TICETO APPLICANT.If, per making this certificate of Exemption.you should become subject in the Workers Compensation pmvWons of the Labor Code,you must '0 O forthwith comply with nen provisoms or Nu permit shall be doomed! nm rked. �► CONSTRUCTION LENDING AGENCY (~ I hereby afrmn that tart is a construction lending agency for tle perfmmaneof a> the wank fur which this permit Is Wised(Sec.3097,Co.C.) W�p Lendara Name 7 z l'ender's Add. U Q 1 certify that I hive read this application and saw WI to above information is IL P cancer.I agree In comply with all city and county oNlnenm and sae laws misting to 0 building construction,and hereby authorize represenmives of this city m enter upon we Lu aeve-menduned property for inspection purposes (We)agree to save,indemnify and keep hamlce,the City of Cupertino agsiml es y liabilities,Judgments.cats and expenses which may In any wayucme against said City U z in comegwnee of to{Mang of this Pamir. y APPLICANT UNDER AND WI COMPLY WITH ALL NON-POI Issued by: 60 Date SOURCE LA S. ! �r Re-roofs $ignaurt of AppliwHAZAR a r ate HAZARDOUS MATERIALSDISCLOSURE mom Type of Roof WIII ase Cutworm, mutebuildingaecupmstore air handle hauNawmateriel defined by to Cupeniw Municipal Code.Ch.pteo Healths 9,13.and the Safety.Section 35532(.)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yw Will the applicant or lawn,bonding awpam on equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hawNmw air contaminants as dcrined by the Bay Arta Air Quality Mwgement all new materials for inspection. Dianct7 ❑Yw P. 1 hive mad the hasard.materials requirements under Chapter 6.95oldie Caliror- meHealth BSacly nde.See=WJ,,34,,,Y[un�rjmdLMLlthe building data ret canctul ve Illwnaufythe.ecu tofde m ulrememswabameanCcei ea f Signature of Applicant Date Owq^ p �a p All roof coverings to be Class"B"or better ner orauthorizedagent Dam Community Development 10p Oemn Cupertino CA 95014 Telephone(408)777-3228 fCl OF Fax(408)777-3333 UPERJJIND Building Department JOB AgqDRESS: �So I� PERMIT # n OWNER'S NAME: 1-109m;d AorAbn PHONE D jl�- Z3 II GENERAL CONTRACTOR: F # 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 • Tile z Li6 Owner/Contractor Signature Date • City of Cupertino Building Department CITY OF 10300 Torre Avenue C U PE RT I N0 Phone: `408""3228 Dear Property Owner. An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner-builder you are the responsible party of record on such a permit Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself,you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work,with the exception of various trades that you plan to subcontract,you should be aware of the following information for your benefit and protection If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer,you must register with the state and federal government as an employer and Wu are subject to several obligations including state and federal income tax withholding,federal social security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers' compensation insurance. For more specific information about your obligations under federal law,contact the Internal Revenue Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your obligations under state law,contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale,property owners who are not licensed contractors are allowed to perform their work personally or through their own employees,without a licensed contractor or subcontractor,only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder building permit,erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors'State License Board in your community or at 1020 N Street,Sacramento,California 95814. Please complete and return the enclosed owner-builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, wilding Department, City of Cupertino Printed on Recycled Paper OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform: A. 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 aLic�uavaTated 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 erformed ..................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information(reverse side). Property Owner's Signaturee:: 2 Date: Q� Job Address: /� e6 I T C D ✓'e.e. 4L& Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. • CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT OPERATOR: amyw COPY # 2 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 37525073 . 00 DATE ISSUED. . . . . . . : 06/23/2006 RECEIPT # . . . . . . . . . : 35001 REFERENCE ID # • • • : 06060204 SITE ADDRESS . . . . . : 18614 LOREE AVE SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : HAMID POURABDOLLAH ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : HAMID POURABDOLLAH CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : HAMID POURABDOLLAH ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , • TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BELEC200 METERS 1 . 00 29 . 43 0 . 00 29 .43 0 . 00 BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 BSEISMICRE VALUATION 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00 ---- ------ -------- -- ---------- ---------- TOTAL PERMIT 103 . 16 0 . 00 103 . 16 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ OTHER 103 . 16 AMEX TOTAL RECEIPT 103 . 16 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL • aC10FCITY OF CUPERTINOCUIPERMIT APPLICATION FORM APN# /1� Date: 102 3/0 Building Ad``d/dress: Mailin A dress (if different from building address): Owne ' Name' Oe _r j /Q//a /_ Phone#: /a\' 313 r �3 11/�iY1I Contractor: 0 Q License#: Contact: O wy,�� Phone: Cupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Set v�2 rcdsz '1P 2 �p Residential ❑ Commercial ❑ Sq.Ft. Floor Area: //O0 Sq.Ft.: 5�cy3a Cost of Project: r �C5© Occupanc Group: Type of Construction: Please check thisboxif the project is a second-story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILER1 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 BUILDING 1 of 3 GHQ. CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM QuantityFee 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 Pb1g 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 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 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace 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 2of3 mCCITY OF CUPERTINO CUPERTINO PERMIT APPLICATION FORM uantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Maz uee 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 Insection 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 Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING • 3 of 3