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04060084 CITY OF CUPERTINO BUILDING DIVISION PERMIT CO_NTRAC�ORTN�'UXtIA.TIUN `,' BUILDING ADDRESS: WALKER CONSTRUCTION PERMITNo04060084 904 OLD TOWN 21 OWNER'S NAME: PERMIT ISSUE DATE FARHAD ETTEHAD 71—B NE: SANITARY NO. CONTROL NO. t (650) 961-7678 ARCHIIECIYENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MEC" 0 t t� o u0o LICENSED CONTRACTOR'S DECLARATION tri I hereby affirm that 1 em licensed under provisions of Chapmr 9(commencing .Job Description n� wiNSemion7")of Division3o(Ne)lusincssa ofmsions Code.andm licensees ^� Nmnmmeand GAS LINE FOR FIREPLACE ��14��® z Lia el Lie.x r De Cam"our 4Q 9AII .ussd l A JUL 'I ace 2004 off 1untlersu my used as Publicreenrtls J1 7 7w!U ,'moo Licensed Profcsaional OWNER-BUILDER DECLARATION BUILDING En O 1 hcmhy.(firm to 11. ,vameptB.sme from Pr Conion,Co License taw far the i❑O fallowing reason.($ecdon]1onstru Business antl w,de i ole Code:Any city car county +�$ which mgmras a permit re ennsuuel,almG improve,h Permit t or repair ed swmum FZi prialmits;ensedprsuntto theres the evisios of for thesuchmns'micensFile ae Law(Chapter ££ss mathmencin withSection70th)ofDiviomn(the the Business ndProfsew(Chodmr9 Sq.Ft. Floor Area Valuation yF0 (mus he Is ...p, ierefan7000)de,Divisioof n asap Professions Code)or $ Net he Is exempt Note(rom antl the hazes far Bethe Alleged cumptlon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty e( NJ1Adnbe10 0 Occupancy e not mom than Eve hundred dollars(5500). P Y TYP ❑Leaowneroftke pmperty,army employees with anagram theirmlecompensation, will tlo me work end meswctum la not intended oroRertd(.nate fSa.704C,Business and Professions Cade:The Conummes License Law item not apply At an owner of Required Inspections property who bui Ids)rim proven Neuron.and who dues such walk himsel f or through his own employees,provided thmsuch improvements are not intended Mattered forsale.If, however,Ne building or improvement is mid within one war ofcompletian,the owner- builder will have the burden of proving that he did not build or improve for purpose of Adm.). ❑I.as Owner of the property,am exclusively contracting with licensed contractors is construct to project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense law docs not apply in en owner of .pan,who builds M improves theme.,and who contracts for such projects with a conte mr(s)licensed pursuant to the Contractor's IRccnse Law. , rX Lm exempt under Sec ,B&P C for this mason t0371W' ner Dam WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury oro of the following dualanti^ns: 1 bare and will main mi.a Card ficate of Consent m self-msura for WorkeM1CamPan. an,v provided for by Section 37M of the Labor Code,for the performance of the k for which this permit is issued. I have and will maintain Workmr's Compensation Inmranm,as required by Section of the tabor Code,for the performance or the work for which this permit is issued. Worker's Compensation Insurance cannot and Policy number am: Cartier: Policy No.: , CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section sued nat he com plc and if the permit is far ane hundred do Ilse(SIM) or less.) 1 ceniry Not' the Performa a of the work for which Permit is issued,I shall nm em to an,pe�tt�aiy�p rySrJn��crm ay�I¢comgaub'e otic Workeri Com nsaRon ' Lawsof CalBdni.PPI �/ / ) - NOT& AP .IL aMaki g Nls Ccrt�ale of Exemption,you should bee. jcct in the Worker's Compensation previsions of the Labor Code,you must ,J O forthwith comply with such provisions or Nis Permit be dimmed ranked. I ,z.i r-r CONSTRUCTION LENDING AGENCY [—r l Mat (Sec. 7,n ding agency for the Performance of ai the work for which this permit is Issued(Sec.31197,Civ.C.) W Q Lenderm 's Nae lit, z Lender's Address - U Q I coldly that 1 have lead this application and sum that the above information is LL F COMact.I agree to comply with all city and county ordinances and sum laws misting to QO building conswctian,and hereby Methodu mprommatives of this city to enter upon Be rA elmve-ms,judg d ....costs .....dxpe ses Purposes. (We)agree m save,indemnify and keep harmless the City of Cupenum against a' incoisequen judgments.ecoats antl Of expenses me men a acrnca a rtseid Cit y g Pc Y� any gi^ Y V z in consequence of the It 'ng Of this Permit. APPLI NT UNDER NDS D WI COMPLY WITH ALL NON-P INT Issued by: DaCCI SOU LATI Re-roofs pplrc HAZARDOUS MATERIALS DISCLOSURE am Type of Roof Will the applicant alNtum building occupant seem or handle hmardous material u defined by the Cataluna Municipal Cade,Chapter 9J2,and the Health and Safety on otic,MY"25532(¢)? No All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future lauding ac)ap.nt am equipment at desires which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air conmeniumas as defined by Nc Bay Area Air Quality Management all new materials for Inspection. District? ❑Yes JtLNu 1 have mad the haxaNOusmamrialarcquimments under Chapmr G95 ofthe Calder. aia Health&SafctyCodc,Sccmms 25505 25533 and 25534,I unwound thatifmc Molding docs note ly ho mnm4 that my mspomih&lity m nod]Y de upanl of the .4 w ich bemc trio issuance or aCcrdfca ofOccu r.. Signature of Applicant Dale o ar aamort a agmen am All roof coverings to be Class"B"or better Community Development - 10300 Torre Avenue yam✓ Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 UPERTINO Building Department JOB ADDRE�a�O RTMUT ro ov G g OWNER'S N �14 ONE # GENERAL CONTRACTOR: 2AX # ju�I am not using any subcontractors: D D 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 d�Ae Contractor Signature ate CITY OF CUPERTINO CUPERTINO PERMIT APPLICATION FORM N # � � Date: D lr D Building Address: Mailing Address (if different from building address): loci Owner's Name: Phone#: Contractor: License #: Contact: C l/,tQ Phone j �O 2 72 Cupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect ❑ Plu Mech ❑ Job besa ' 1 � 7C47L7 Residential 6A& 11AIE � �>,-1,5 104 l ❑ Commercial Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: / Occupancy Gro i Type of Construct on: Please check this project is a second-story addition: ❑ ro'ect Size: Standard ❑ Large ❑ Major ❑ uanti Fee ID Fee Descri tion Fee Grou BAPPLOTHER Other A liances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL .BCONSTAX Construction Tax BUILDING BCONSTAX lnd/Off/Comm/ unci BUILDING BCONSTAXB 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 Ener BUILDING BENERGYADD Ener Add Multi BUILDING BINVESTIGA Investi ation fee BUILDING 1 of 07 'ail CITY OF CUPERTINO CUP TYOF NO 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 Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Cbeck 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 Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREW! RN 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 2 of 3 t CITY OF CUPERTINO CUPIT 0 EkTINO PERMIT APPLICATION FORM 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 Insection BUILDING BSyVIM Swinuning Pool BUILDING , BTEMP I 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 ZADDCHG Address Chane BUILDING mW 3 of 3