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05070072 CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION BUILDING ADDIj E55: GT ELECTRIC PERMIT NO..5070072 10403 NO V ER'S NAME: PERMIT ISSUE DATE PARVIZ KHODI 861 WI PHONE: SANITARY NO. CONTROL N0. (408) 362-9473 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 L O S DECLARATION IninetyiflirlmdualElamCONTRAlicensed wild.,pmviumn.rchapw9(commencing Job Description vim5arce ndcfffDrvivonlof the Butnruand Prafestmns Code.and myliccnscis s�,a ��® n full forte.lea eR [�-�y' ,.,AS �'q= a«nm cla.. � fjo Lie,a 7 Tet �, � CHANGE OUT MAIN 100 z�c Dam Citmanor AND SUB PANEL. ARCHITECTS DECLARATION I muthrstand my ph s anJll used u public records �y ^/ n 3u.t, Licensed Professional ��� //40_ 5 OWNER-BUILDER DECLARATION a. J A l I Wrehy affirm Nat I am exempt from the Conlracmr's License Law for the 00 following mason.(Smuon 703 1.3,Butincss and Pmfessioen Code:Any city or county imp $ which nery.musis Permit to cntnt L k1w.improve,demolish,or ra,d,any structure rZe parmtuissua.0....roquims the applicant for such permit to file a signed summcnt E€O that he is licensed punuenuo the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area4 a�qrl`700 m (commending with Section 7000)of Division 3 of the Business and Professions Codc)at Nn he is emmpt themfmm and the basis for the alleged exemption.Any violaJon of Section 703 L5 by any applicant for a permit subjects the applicant to a civil penally of noAPN Number Occupancy t roam man five hundred donors(s5ao). 32647064 . 00 p y T ype 1,Mownerofdgpropusy,mmyuaploymwithwgouthe'trmlcco Nmoon, will do the work,Coad dm saucun u wt intended ma w doss Out a(Sec.toad,Business and Property bis Calc:The Coaimproves t hereon, fid who Law dm fiat apply lf an rough is Required Inspections Own enywhobuilds or Oat such improvements who do not inendesuch dm muttered his own employm,provided m r such improvement an not ear ofo moRemd for sale,Owner.. builder rebuilding Orimprovementu oldwithinroteyear of completion,Ne eof builder will nave the Wradcn Of proving Nat W tlitl not Wild or improve for purpose of tile.). ❑1,as Owner of the property,am exclusively contracting with licensed cantrumn to cm al net Bic project(Sec.7004,Business and Professions Cods:)The Cinnamon'.Li- cense law docs not apply in in owner of property who Wilds or improves dialect.and who contacts for ouch Projects with a convantor(s)licensed pursuant in the Contactors License Law [:]I am cacmpt under Sec. B k P C for It,loans Far Data WORKER'S COMPENSATION DECLARATION 1 kmby affirm under Penalty of perjury one of the fallowing decluatiore: ❑I haw and will maintain•Ce r3mwof Cammnitoutf-insumfmWortersCampcn- uttmn,as provided for by Section 37x0 of the Latin,Code.for me petrmmanaz of the work for which mil permit is Issued. n 1 have and will maintain Worker's Compensation Insurance,as requited by Section 3700 of the Ube,Code,for the performance of the work for which this pertit is issued. My Worleri Compensation Inman¢carrier and Poliry,number are Carver. Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE or lcsxJ(Thu maim need not be completed if tW permit is formic hundred dollars(S IqO I eenif-v mat in me Performance of the work far which this Permit to issued,l shall not ..Ploy any permo in any in azmby omc uj to thoWoken'Cmrarisstfan ' Law.of California.Da Applicant NOTICE T10 If,after making this e d roam of Eacmption,you should become subject an me Worker's Compensation provisions Of the Litton.Code.you most ., ,'Z fomwide comply with such provisions or this lark shall be dcemmd revoked. zO CONSTRUCTION LENDING AGENCY [—m I hereby affirm that then is a conslrucdon]coding agency for the performance of LYm the work for which this permit is issued(Sec.3097,Civ.C.) GQ Under.Name = Z Lenders AdOcis U0 L cenifY mal 1 haw lead this applie sid.and sues mat the above information is IL, F comi 1 agree b comply with all city and county aNiaal6C.and stele lawd nixing to OU Wilding con.enaction,and herby autharin repnscntamea of this city in enter upon me yabove-mentioned property for inspection purposes, (We)ague to ave,indemnify and keep hCnnless the City of Cupertino against (n liabilities,judgments.costs and expenses which may In any way accrue againstmid City t),z in eonseq�uence a(thc graining of this .it. APPF-m SOULII{CE REGUNDERS�AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 7- ^ �'1�-0 Re-roofs Sds Of ppucam.trachn Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will dm applicant or future Wilding occupant sort m handle ham drus material as derided by tW Cupertino Manual Code.Chapter 9.13,end the Health and Safety Cade.section 25532(a)? - ❑Yes All roofs shall be inspected prior to any roofing material being installed. ]Nm Will the airplicantorfuture building acupamumequipment ordevices which If a roof is installed without first obtaining an inspection,I agree to remove coil haommirs it mnnminanu az dolmed by the Bay Ana Ail Quality Management all new materials for inspection. District? I ❑Yes 1-1 No 1 have roml the buomlours mtdoludsrequismcntiunder Chapter 6.95 of me C,i1 for- nix Health h Safety Coat,sections 35505,25533 and 35534.1 i ndcrsund mu ifthe Wilding dos not cu rcml a tenant,Out it u my responsibility an notify lW axupant of me requirements wh hm tWmel dy�missu woft CeniIII of Occupancy. p/ !✓�—�7 f rG� Signature of Applicant Date Owner araumcur.d.9clu D,m All roof coverings to be Class "B"or better Community Development F 10300 Torre Avenue ( Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ISUPERTINO Building Department JOB ADDRESS: PERMIT # 0 L4o -3 No S07do72, OWNER'S NAME: 06k 2 d i Kk- PHONE # L-1 OS'- 7 91 - O GENERAL CONTRACTOR — El FAX # I am not using any subcontractors: 7-/` -c, Signature Date Please check applicable subcontractors and complete the followinginformation: 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 Owner/Contractor Signature Date CITY OF CUPERTINO Io 1 Of 1 PERMIT RECEIPT OPERATOR: Buem COPY # 2 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32647064.00 DATE ISSUED. . . . . . . : 07/13/2005 RECEIPT #. . . . . . . . . : 30343 REFERENCE ID # . . . : 05070072 SITE ADDRESS . . . . . : 10403 NOEL AV SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : PARVIZ KHODI ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1229 RECEIVED FROM . . . . : THOMAS MUNSON CONTRACTOR . . . . . . . : TOM MUNSON LIC # 24731 COMPANY . . . . . . . . . . : GT ELECTRIC ADDRESS . . . . . . . . . . : 861 WINDSON HILLS CIR CITY/STATE/ZIP . . . : SAN JOSE, CA 95123 • TELEPHONE . . . . . . . . : (408)362-9473 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BENERGY PERMIT FEE 83.16 39.92 0.00 39.92 0.00 BELEC200 METERS 2.00 58.86 0.00 58.86 0.00 BPERMFEE VALUATION 2, 700.00 83.16 0.00 83.16 0.00 EPERMITFEE FLAT RATE 1.00 38.37 0.00 38 .37 0.00 BSEISMICRE VALUATION 2,700.00 0.50 0.00 0.50 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 220.81 0.00 220.81 0.00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ _----_-_---------_ OTHER 220.81 VISA TOTAL RECEIPT 220.81 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL • CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM • CUPEkTINO t125�;�207� APN # 7 /�/ Date: (/lam d Building Address: Mailing Address (if different from building address): *v��No ,d 10903 Own e 's Name: Phone#: C *, ,L, Ko 1-10 r7 8f- 0 A 4 Contractor: License #: 6T 7s- o 46 Contact: Phone: 7 Yl- OS 9 7 Cupertino Business License#: l,_ { k V Som Fax: Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: {�. ct S„p Residential Er CGS c UvT Yk.,, LQOA Ta ElSq.Ft. Floor Area: $/Sq.Ft.: Cost of P1ect: 00 Occup c(Group: IY p1 Type of Construction: Please check this box if the project is a second-story addition: Pro'ect Size: Standard❑ Large ❑ Ma or ❑ --- - - Quanti 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 BCONSTTO 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 alo CITY OF CUPERTINO CU PNO PERMIT APPLICATION FORM uanti 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 Cess ool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE PbIg 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 rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reins ection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfln 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> I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc A aratus ELECTRICAL BREMNRAPP Rem Non-Res A Hance 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 2 of 3 "u- CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM ' CUPEkTINO Quantity Fee ID Fee Description Fee Grou • BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL BREMTHEATR Theatrical LightiDg 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