06090003 CITY OF CUPERTINO 7e^ - '
BUILDING DIVISION PERMIT x ,0N1RACT0R INFYURMATIO
BUILDING ADDRESS: ALI AHMADIEH YAZDI PERMIT NO.06090003
10241 RANCHO PL if A
OWNER'S NAME: PERMIT ISSUE DATE
ALI AHMADIEH YAZDI
NE:
SANITARY NO. CONTROL NO,
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
of LICENSED CONTRACTOR'S DECLARATION Job Description
m❑ I thereby affirm doer 1 am licensed umler provisions of Chapter 9(commencing
:ZW with Section 7011))of Division 3 of due Business aw Prefessiom Code,and my license
miollfemeamcinffect. DEMOLISHING EXISTING POOL AT REAR LOCATION
? License Class Lima
iF Dau: Conuxcmr
ARCHDECTS DECLARATION
1 Command my plans albdl W used as public memds
C.
o Licensed Proremional
OWNER-BUILDER DECLARATION
or
I hereby affirm that 1 am exempt from the Conumero's Limme Law for the
O C fallowing..on.(5ca6un Nn 1.5,Business and Prokasime Cock:My city or county
which¢quire a permit to...L alum,improve.demoleh,or.pair any swmu. 10 0
�9Y prior us its issuance.also requites the applicam for such permit on rile a signed suamem
that W is licensed pursuant to thc provisions of the Conuaao/s Linn¢Law(Chapter 9 Sq.Ft. Floor Area Valuation
(commencing with Section 7")of Division 3 of NC Business and Professions Com)or
j that W is exempt therefrom and the basis for the Moped exemption.Any violation of
Section 7031.5 by any applicant for a permit subjec s the applicant In a civil penalty of o f Occupancy Type
not mom roan rive hundred dollars($500).
❑I.ss owner of Ne property,or my employees with wages as their sole compcommon,
will do the work.and Ne someon a not intended ser offered Or sale(Sec.70".Buurcss
and Professions Code The Canuacmh License iLawms dos not apply lf an owrcr Of
is Required Inspections
property who Wiprovid d dovrt Hereon,and who Am not in work himself or through his -
ow aver. Yens,provided thmmch improvements art not ear dedofc oroffeapron n.for ala U.
builder.rhe Wet heorimprovementismadwithin one year of mproefor the Owner.
builder will have dm burden of proving that Ire did not build or improve far purpose of
P,.,r/e.). /OG
( •,u owner or the pmpcmy,am exclusively contracting with licensed conmmors m
come La the project(Sec.7044.Business caw property
who
Cade:)The Conhemon. nd
cane Law does rnor such
m m owner of property who Wilds or improm dm.on,and
whence Lace far such projctts with a camracmms)licensed pursuant to rhe Unmttofs rs�s
Lice
❑Ivor acmptde
unr .BSPCfor Nm
e roan
OwnerDate 11�^��
RKER'SCO SATION DECLARATION
1 hereby affirm under aRy of perjury am of the following declarations:
I ham and will maintain a CerdBam of Careen to self-imum for WoNeYs Compere
Prion,an providedi for by Second 3700 of dee Labor Code,for the performance of tha
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,As mquimd by Section
37W of use Lmm Code,for the performance of the woo for which this pcmrit is issued. '
My Warkces Compensation Insurance artier and Policy number a.:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
OTU section need not he complcmd if the Permit is forone hundred dollars(SIW)
less)
1 certify that in the perfarmence of the work NO which this permit Is issued,l shall nor .
cmpleY any person in any manner"u ba dens_Pbjec�Ne Workers'Comcm
pauon
Laws of Califamia.Dam T'—a
Applicant
NOTICE TO APPLICANT.If. ft,iraffinfillft CtmTkallin,you should
become auhjen in the Worker's Compensation provisions of the Labor Code.you must
^J az
forthwith comply with such provis ons or the permit shall W domed mvknd.
Z O CONSTRUCTION LENDING AGENCY
F" I Wmby aRrm that then is a comructon lending agency for the perfurmmm of
!Yi the wed for which the permit is issued(sec.3097,Civ.C.)
6W.Q LendeYs Name
7 z Lcrumes Adel=
U0 1 certify that 1 have tend this application and sou Nn the aWve infonnsdon e
D, H correct.l agree to comply with all city and county ordinances and sum laws miming to
0 building construction,and hereby authmire mpmx^urives of his city to cnler upon rbc
a
above-mentioned property for impaction purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino agaimt
F VI liabilitia.judgmenu.emu and expenses which may in my way aecme against Pid City
Uz in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND W LL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGXT10�j
signa�af ApplicanUCon Dam or Re-roofs
x OUSMATERIALSDISCLOSURE Type of Roof
Will the applicant or forum Wilding ampmt atom or handle hamumus ma.rial
m defined by dm Cupertino Municipal Code.Chapter 9.13,and the Health and Safely
I ewe.SecQYna 25532(a)7 J;rNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding attvpant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
. emir hayarwua air conuminanu as defined by the Bay Area Air Quality Management all new materials for inspection.
Diabrict?
❑Yin QNu
I have mad on,hvardoesma.nils requirements under Chapmr 6.95 of dm Califor-
niallcalOm&Safety Calc,Sets.25505.15533 and 25534.1 undcrsund thmlldm Wilding
does trot,.nand,have ate A. be i e my me mibilfly to nwfy she occupant of rW
mquincon w must At miss ofa cerdficam of Decor.,
Signature of Applicant Date
ownerar,a ge D,m. . All roof coverings to be Class "B"or better
.», Community Development
10300 Torre Avenue
Fy' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
OUPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
o z�(l 015 d raoo 3
OWNER'S NAME: q L &H�AO G.V-,)104 ga PHONE # yo g 9 9 8s 2
GENERAL CONTRACTOR d FAX #
I am not using any subcontractors:
Signa Date
Please check applicable subwmg 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
Owner ntractor Signature ��Date
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
• A. All 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
t l
• 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
performed
.....................................................................................................................................................................................
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 Signature: Date: 9- l - 2 o a 6'
job Address: /a t Y i A A, c.v.,/!. of n Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
• Department.
ag' ',
IM
City of Cupertino Building Departmen
' I pCIITY OF A' 10300 Torre Avenue
C V r C[�T I I V o Phone: (408)777-3228
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 vourself 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 pian 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
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers compensation insurance,disability insurance costs,and unemployment compensatior•
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 penmit,will not-be issued until the.verification is returned.
Very truly yours,
Building Department, •
City of Cupertino
Printed on Recycled Paper
CITY OF CUPERTINO
*am 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35703014 . 00
DATE ISSUED. . . . . . . : 09/01/2006
RECEIPT # . . . . . . . . . : 35873
REFERENCE ID # . . . : 06090003
SITE ADDRESS . . . . . : 10241 RANCHO PL # A
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : ALI AHMADIEH YAZDI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : ALI AHMADIEH YAZDI
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : ALI AHMADIEH YAZDI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------ - - - ---- ------- --- --------- - ---------- ------ - --- --------- -
BPERMFEE VALUATION 1, 000 . 00 83 . 16 0 . 00 83 . 16 0 . 00
BSEISMICRE VALUATION 100 . 00 0 . 50 0 . 00 0 . 50 0 . 00
---------- -- - ------- --------- - ----------
TOTAL PERMIT 83 . 66 0 . 00 83 . 66 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
---------- - ------ - - ---------- -------- ----------
OTHER 83 . 66 VISA
TOTAL RECEIPT 83 . 66
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
704 DEMO
•
CITY OF CUPERTINO
`€mli-
DEMO
O
• CUPER INO PERMIT APPLICATION FORM
APN# 3 6' 7- 03 - o / y
Building Address:
/'2 y/ o 41. A
Owner's Name: Phone#:
A L AH," E w o ' VC C, zz
Contractor: License#:
OW
Contact: Phone#:
O & ,. �r
Applicant/Contractor:
Building Permit Info:
ld Elect Plumb Mech
Job Description: A , /t fn.r L o rA7lo,..
Residential: DFMoLiroG fvis7/NG ooL Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
/oo
. Type of Construction: Occupant Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG.
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUIL IDNG
•