081000580
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CITY OF CUPERTINO
TNF,U,,,RMATIIV
BUILDING DIVISION PERMIT
C�1ri�TRACTQR ;
BGI1V1Tt"kRTHBR00K SQ
BEHNAZVARASTEH
PERMIT NO.
08100058 ,
OWNER'S NAME:
PERMIT ISSUE DATE
BEHNAZ VARASTEH
20336 NORTHBROOK SQ
10/10/2008
NE:
SANITARY NO. CONTROL NO.
ARCHITEC iENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
1 hereby affirm that 1 are licensed under pmvismins of Chapter 9 (enmmeremi;
with Section 7M) of Division 3ofthe Business and Professions Code.and my license is
SVC CHANGE OUT/UPGRADE ELECT
in full force and effeel.
License Class Lk.0
Dam Contractor
ARCHITECTS DECLARATION
1 understand my Plans shall he axilu public recnNa
Licensed Pmfessiovl
OWNER-BUIIAER DECLARATION
I hereby, aliirm that I am exempt from the Contractus License Law for tW
following reason. (Saudis 7(n 1.5, Business and Profusions Cods: Any city or county
which regmiros , pared to muslmct. alcor, nnplave, demalkh, m roPon any --in-
prior W of issuance. elm acquires the applieml for such permit in rile a signed statement
Contrsemr'f License Law (chapter 9
Sq. Ft. Floor Area
Valuation
dui he is licensed purntant to the provisions of the
500
and Pressiam m Cade)
(commencing with Section?0DO) of Division 3 of the Business m
that he u exempt therefrom and the hosts for the alleged exemption. Any violation of
316 3 9 013 .°'Efi'l�
- Occupancy
Penc Y Type
Section 70313 by any applicant for a permk subjects the applicant m a civil Penalty OfNumber
rel tomo man five hundred dmlars ISSDDI.
01,uawnsofticpmprty.wmywploymwithmguuthehmkc Nnmdon,
Required Inspections
will do the work and the structure Is not inmoded or offered (mask (See. Ti)ch, Ron.
and Professions Cane: The Contractors License Law does nal apply m an owner of
pmpeitywnd Wildaorimpomthermn,andwnddatatanworkhimselfar through his
awn employer. provided that such improvements son, not jus, ded araRered forule V.
however, One Wilding or improvement is mid within rex Year of completion. the manner -
builder will have the Weaken of paving that W did ret Wild or improve for purpose of
.In.).
❑ 1. as owner of the property, am exclusively contracting with licensed mnuacxam an
consuact the project (See. TOaq, Business sod Pmfessov Cade) The Conlrxmr's Li-
«ve law does not apply to in owner of property who Wilda or improm Neacon, and,
who contracts for such projects with a rnnwcter(s) licensed pursuant to the Conveners
License law.
❑ 1 ren seem under Se/e G B ✓k P��Cs(o�r t,lsfiys in,"_
Owner CI, //!i"Y Data ty;ya p
—TV
OA5SR"SCOMPFNSATION DECLARATION
I hereby, aRkm molar perWly of perjury me of the following dalmatians:
I have and will maintain a Certitinm of Covent as self -boom for WorkersCamper-
suion, an provided for by Section 37M of the labor Code. for the performance of me
work for which our permit is named.
❑ I have and will maintain Worker. Compensation Ivarance, u acquired by section
3700.1 the land, Cole. for the performance of the work for which this permil'm Issued
My Workers Compewtion Insurance urtiat and Policy number aro:
.
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sttsion need relnd completed if tic permit Is Toone hundred dollar ($100)
or ksv)
1 eerrify that in the perfonna e, of the work for which this Permit is Wind. l "I no
employ any person in any manvrm�hbeeo�cmbycI m the Winters' Compensation
(& LL hh
lawn of Ctlif it .Aiin !loll
.
Applicant
'
NOTICE TO APPLIC�1 : If, after making this Cci iricat, of Exemption, you should
become aubjm m f ricer's Compensation provisions of the L mor Code. you an=
' forthwith comply v. men provuinns or suis peaniuhall be deemed rowkcd.
LENDING AGENCY
CONSmisac
1 nor which ml mCR is nu (Sec.30 lending.Cv.agency for do pCffafmalla of
• the wars acv which this permit ta issued (sea. 3097. civ. G)
pe s ed
Lenders Name
,
landeh Address
j 1 certify mat 1 have Rad this application and mule this the aWve iMarnauon u
'
' cannot. 1 agree an comply with all city and county ordinanm and sum laws relating to
Wilding conssmandon, and hereby authorise representatives of this city in an= upon the
andve-mentioned property, for inspection purposes
(We) agree m save, indemnify and kap harmless the City of Cupertino against
j Iimilidu,Judgments. cams andexpernn which may In any way acme against mid Gly
in consequence of the grantinjof this parfait
I APPLICAT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
souacga(g
9J vZGut�p
Re-roofs
/
Type of Roof
Si urtaf ranYCoaunctor Data
I �
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fmluse building occupant same o, hasWle hxoudau material
as &flood by the Cupertino Municipal Code. Chapter 9.17, and the Heave and Safety
-
Code. Section 75533(x)?
All roofs shall be inspected nor to an roofing material being installed.
P P Y g
Dyes �lo
g-
If a roof is installed without first obtaining an inspection, I agree to remove-
N`ul the applicant or future Wilding occupant use equipment dr dcvim which
. hnardnns air concomitants; u defined by de Bay Area Air Qmlity Management
all new materials for inspection.
ncA
❑ Yn o
I have road the huudous materials requirements under Chapter 6.95 ofthe Califor.
NaHglmkSafetyCodc 75505,75533 and 25534.1 uMeraand Wt ifthe Winding
dm not cunenity nave eat. mal it u my RapensibilitY a naul'Y de occupant a(the
oet,�j.
inquirywhk eametpkrmivaocenr,cmtirm/Jr �
Signature of Applicant Date
At WGam'
All roof coverings to be Class'W' or better
–tor Data
04.41t OIVL igt"I
'
• 4 ITEMS OF 4
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 31639013.00
DATE ISSUED.......: 10/10/2008
RECEIPT #.........: BS000006320
REFERENCE ID # ...: 08100058
SITE ADDRESS .....: 20336 NORTHBROOK SQ
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: BEHNAZ VARASTEH
ADDRESS ..:.......: 20336 NORTHBROOK SQ
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: BEHNAZ V MORGAN
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: BEHNAZ VARASTEH
ADDRESS ..........: 20336 NORTHBROOK SQ
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE ........:
OPERATOR: pdtg
COPY # : 1
is FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
1BSEISMICR
VALUATION
500.00
0.50
0.00
0.50
0.00
1EPERMITFE
FLAT RATE
1.00
40.79
0.00
40.79
0.00
1ERT<200
UNITS
1.00
40.79
0.00
40.79
0.00
1TRAVDOC
FLAT RATE
1.00
40.79
0.00
40.79
0.00
TOTAL PERMIT
122.87
0.00
122.87
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
0
AMOUNT
---------------
122.87
---------------
122.87
REFERENCE NUMBER
--------------------
AMEX
ays, CITY OF CUPERTINO
• CUPWINO GENERAL BUILDING
PERMIT APPLICATION FORM
•
•
6A1 (D o 3s?
APN # / (a 3 O
Date: 1000-2-60?,
Building Address:
203310 AIOi-A&0012
j ('& per
h'ti CA 950/
Mailing Address (if different from building
dress):
Owner's Name: b
�k z liar
s h
Phone #:
08) Zl
Contractor:
Phone:
(� iJ
Fax:
Contractor License #:
Cupertino Business License #:
Contact:
Phone:
Fax:
Residential Commercial
Job Description:
ChanJ e, U&
ar
Building Permit Info:.
/
BldgEl Elect C3
Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV -HT, V -B
1� —
Valuation:
pv =5c�
Square Footage:
Project Size: Ex ressStandard ❑
Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index,
Points Achieved:
For help, contact Build it Green at www.builditlZreen.org
Revised 7/01/08
CI OF
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf
Fee ID
Fee Description
Fee
Permit Type
Group
1GENRES or
1 GENCOM
1 BBOILERI
For the installation or relocation of ea
M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h 29.3kw .
1 BBOILER2
Installation /relocation of ea
M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1 BBOILER3
Installation/relocation of ea
M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1 BBOILER4
Installation/relocation of ea
M
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1•,000,000 Btu/h to
& incl 1,750,000 Btu/h
1 BBOILER5
Installation/relocation of ea boiler or
M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1 BAPPLOTH
For ea appliance or piece of equip
M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
1 ELECINSP
Other Electrical Inspections (per hour)
E
1MECHINSP
Other Mechanical Inspections (per
M
hour)
1 PLMBINSP
Other Plumbing & Gas Inspections
P
(per hour)
1MEETINGIHR
Application Meeting
B
E
•
E