07010036 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
411 BEARDON DR MANSOUR
PERMIT ISSUE DATE
OWNER'S NAME:
MANSOUR KAVIANPOUR 10411 BEARDON DR 01/05/2007
SANITARY NO. CONTROL NO.
JNE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
4 U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing INSTALLING TEMPORARY POWER POLE
=Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and effect.r2 �; v t
? License Cans 1 Lk.8 0V
t O Date Contractor •�
'ARCHITECTS DECLA
W,V I understand my plans shall he used as public records
a
4 0 Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
E 0 o following reason.(Section 7031.5,Business and Professions Code:Any city or county
e$ which requires a permit to construct,alter,improve,demolish,or repair any structure
Z; prior to its issuance,also requires the applicant for such permit to file a signed statement ; ,Ft.Floor Area Valuation
=C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $3 0 0
F $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 32630126 APN Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended oroffered forsale(Sec.7044.Business Required Inspections
and Professions Code:The Conuactoes License Law does not apply to an owner of
property who builds or impmves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
IYJ t have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is Cor otic hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manne�s�aj t^bcSp 'wb' l to the Workcrs'Compensation
Laws of califg�ctia.Date— Ccs
Applicant IL I i w PSTP?.
NCrnCETOFAYP—IJCArii@tjAlrthis Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
p;> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
�M Lenders Address
U 1 certify that 1 have read this application and state that the above information is
V> 0— COMM I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
CA liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
90-4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date J�
SOURCE RE TIONS.
01 10 0_t Re-roofs
Sign o 0 or Date
H OUS MATERIALS DISCLOSURE Type of F.00f
Will the appli t future building occupant store or handle hazardous material
as dcftned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ,�Nri
Will the applicant or future building occupant use equipment or devices which If a roof.;s installed without first obtaining an inspection,I agree to remove
:mit hazardous air contamina7N.
defined by the Bay Arca Air Quality Management all new Materials for inspection.
District?
❑Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements wh'h themet priorto issuance of a Ccrtifjpatc of Occup cy. Signature of Applicant Date
A 94 All roof coverings to be Class"B'or better
Own a a Datc'
Community Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
`'UPEkTINO
Buildin De artment
JOB ADDRESS: `�� " D� PERMIT#
OWNER'S NAME: tk u f Q V la e� D V\r PHONE #-4,09)
GENERAL CONTRACTOR: L i ' Co/' FAX #2 D
7-1�2 Tat\ /0 -//c
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
Owner/Contractor Signature Date
` �
a
CITY OF (,UPERTINO
et
TP POWER
CUPEkTINO PERMIT APPLICATION FORM
APN# 32,^ 30-'12I0 Date:
Building Address: I cal ,/
oll
Owner's Name: I Phone
Ac(a p Lki/ Ka U( b m- -('ve
Contractor: ,?hone: License#: C
Co t ct:, Phone: Cupertino Business License #:
Building Permit Info:, 1
Elect ®/_
Job Description: - -
Residential Commercial ❑
Cost of Project: 4K29,��,
3c°
Qty. if
Applicable Fee ID Fee Description Fee Group
f BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING