12020080 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20916 FARGO DR CONTRACTOR:SEYEDIN FAMILY PERMIT NO: 12020080
TRUST
OWNER'S NAME: SEYEDIN FAMILY TRUST 20916 FARGO DR DATE ISSUED:02/17/2012
OWNER'S PHONE: 4083953222 C_'UPERTINO,CA 95014 PHONE NO:
11
❑ LIC'ENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL® COMMERCIAL
License Class Lie.#
TEMP POWER POLE
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that nhv license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
pert6rmance of the work for whichthis permit is issued. Sq.Ft Floor Area: Valuation:$800
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of die work for which this APN Number:32630114.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter /
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA ' ,�OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs.,and expenses which may accrue against said City in consequence of the Issued by: ��/ v Date ( `"
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole cotarnsatiort,
will do the work,imd the stricture is not intended or offered for sale(Sec.7044,
Business&Professions Code)
HAZARDOUS MATERIALS DISCLOSURE
1,as owner of the property,an,exclusively contracting with licensed contractors to
construct the proiect(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
� A California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following flu a maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contartrinants as defined by flee Bay Area Air Quality, Management District I
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety Code,Sections 25505,25533 and 25534.
7//,—
Section 3 700 of the Labor Code,for the performance of die work for which this Owner or authorized age- g Dat
permit is issued.
I certify that in the performance of the work for which this permit is issued,Ishan
not employ any person in any rnathner so as to becorne subject to the Worker's f ONSTRUCTION LENDING ADEN
Compensation laws of California. If,after making this certificate of exemption,I
become suhiect to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued(Sec.3097,Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnity and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source re ulatir�per the Cuperti -) Mkyliclp l(�oche,Section G icetrsed Professional
9.18.
Signature Date_2�LL
CITY OF CUPERTINO
PERMIT RECEIPT OPERATOR: SylviaM
6 ITEMS OF 6 COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32630114 .00
DATE ISSUED. . . . . . . 02000016057
17/2012
RECEIPT #. . . . . . . . .
REFERENCE ID # 12020080
SITE ADDRESS 20916 FARGO DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER SEYEDIN FAMILY TRUST
ADDRESS 20916 FARGO DR
CITY/STATE/ZIP CUPERTINO, CA 95014
RECEIVED FROM SARA SEYEDIN
CONTRACTOR LIC # *OWNER*
COMPANY SEi'EDIN FAMILY TRUST
ADDRESS 20916 FARGO DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
UNIT QUANTITY AMOUNT ----
PD-TO-DT THIS REC_ NEWBAL_
--FEE ID ---------
__ -
----------
----------
------
---- 1 .00 41.00 0 .00 41 .00 0 .0
1ADMIN HOURS 800 .00 1. 00 0 . 00 1.00 0 . 00
1BCBSC VALUATION 0 .50 0 .00 0 .50 0 .00
1BSEISMICR VALUATION 800 .00
1 .00 44 .00 0. 00 44 .00 0 .00
1EPERMITFE FLAT RATE 44 .00 0 . 00
IERT<200 UNITS 1.00 44 . 00 0 .00
100 44 .00 0 .00 44 .00 0 .00
.
1TFAVDOC FLAT RATE ----------
TOTAL PERMIT174 .50 0 . 00 ----174 .50 0 .00
METHOD OF PAYMENT
AMOUNT REFERENCE NUMBER
------------
--------------- --------
CREDIT CARD 174 . 50 me
---------------
TOTAL RECEIPT 174 . 50
VOICE ID DESCRIPTION
VOICE ID DESCRIPTION
________ _________________
402 TEMPORARY POWER
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333- buildlnQ(Q�CUDertlnc.OrQ
CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
APN BP#
SITE ADDRESS `
OW ER NAME
OWNER ADDRESS f� �� _ U
-, J
DESCRIPTION OF WORK:
We are providing you with an Owner-Builder Acknowledgment
d InforlaVerification
� orm to make you aware�
your responsibilities and possible risk you may cubYav ng thpemitssuedn your as the Owner-Builder.
ed your
of each
will not issue a building permit until you have
indicated! An agent of the ownergannot execute thisnotice unless
you,
returned this form to us at our official address
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFO RMAToION d r and orrify f f a i
(DIRECTIONS:Please l a and initial each statement below to signify yZ 61
, frequent practice of unlicensed persons is to have the property owner obtain an"Owner-`�
/� f�dersltandildia a fr q is
Builder" building permit that erroneously implies the property
serious providing I rlabor and
material
personally. I, as an Owner-Builder, may be hlIableand sbject to fnanI risk for injuries sustained by
M homeowner's insurance may not
an unlicensed person and his or her employees while working on my property. Y
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
N�2. I understand building
pits are not required to be signed by property owners unless they are responsible for
jon an are not hiring a lice
truc on Contractor to assume this responsibility
the coo .
/ m �
I
that I
�3. 1 understand as an "Owner-Builder'bhminharlicensed Contractor randrhav ng the permit filed ind on the permit. Ich sdor her may
protect myself from potential financial risky 9
name instead of my`own.
,r� P./
4. understand Contractors are required by law to be licensed and bonded in California and to list their license
)�Ambersermits nd contracts.
on p (2--
,�5. I
r 7��'f� /',>understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
___
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an ,emplo er" under state and federal law.
I must!� al law,
6. 1 understand if I am considered an"employer"wo�kees' compenr state sation onrdisability insurance, and contribute to
nd
federal government,withhold payroll taxes, p Iso understand my failure to abide by these laws may subject
unemployment compensation for each "employee. I a
me to serious f nanciyaI risk.
er
ngle
7. I understand under California Contractors'
hem with the eintent to offer themLicense Law, an forsale, unless halbwo sl performed by
residential structures cannot legally build
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is perfgr ned under c�act with a licensed general building Contractor.
�8 1 undersand as an Owner-Builder ifbl sell the subsequent ownelch this r(s)thapeesulltls issued, I may from any latent bonstrheld
ctionliable or
any financial or personal injuries sustained y y
defects in the workmanship or materials. pii,nerBuilderFo,-n7_2010.doc revised 04119/10
'AA9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service,the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.esib.ca.gov for more information about licensed
contractors.
� � lied for in m name, and understand that I
AJ-10. I am aware of and consent to an Owner der building permit app Y
am the pa leg Ily and financially responsible for proposed construction activity at the site address listed above.
-ralnpP, l-,
1. I agree that, as the party legally and financially resrs as well as employers.ponsible for this proposed construction activity, I will abide
A,Ll
by alt applicable I w/s and requirements that govern Owner-Builde
��P P
JX/ the
I1�L. I agree to notify the issuer of thi Licensed codnitraclt�s are regulated by laws des gned to protect thef any additions, deletions, or changes to any f public. If
rm imme
information I have provided on this form may
le to
you contract with someone who does not
sustainhave a )as a result o�atcomplaintt Yourate only remedy emeddy against unlicensed
assist you with any financial loss you may cense
Contractors may be in civil court. it is also important for you to understand that if an
li held d Contractor
for damages. If
or
employee of that individual or firm is injured while working on your property, y may
le for verifying
you obtain a permit as Owner-Builder and and the status of their workers' compensation
lt� iibsurance coveragewhether or not
those Contractors are properly licensed an
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
ner and
Before a building permit can be issued,this
rm the ust be ermit. Note.!eted and signed by the A copy of e property y owner''s driver's license,
returned to the agency responsible for issuing P
form notarization, or other verification acceptable to the city may be required to be pre ented when the permit is issued
to verify the property owner's si nature. S Date:
Property Owner's Signature:
-- ----- -------------- ----------------------------------------------------------------------------------- - -- - --
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
construction permit for the Owner-Builder).
agent of the property owner to apply for a
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Tel No
Name of Authorized Agent:
Address of Authorized Agent:
rsonally
he
I declare under penalty of perjury that I am the proper Y of the for prop
owner'listed )river's license, form notarization,ed out t
tion, orother
above information and certify its accuracy. Note:A copy P
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Date:
Property Owner's Signature:
GxvnerBuilderForm_2010.doc revised 04/14/10
= M E T R O S C A N P R O P E R T Y P R O F I L E _
Santa Clara (CA)
*
*
*
*
*
*
* < < < OWNERSHIP INFORMATION > > >
*
Parcel Number :326 30 114
Owner :Seyedin Family Trust
Bldg Id No : 1
*
* CoOwner
* Site Address : 20916 Fargo Dr Cupertino 95014
* Mail Address : 17110 Scott Dr Monte Sereno Ca 95030
* Phone :Owner:
*
*
* < < < SALES AND LOAN INFORMATION > >
*
* Transferred : 12/05/2011 Loan Amount
* Document # :21444411 Lender
* Sale Price :$990, 000 Full Loan Type
* Interest Type *
Deed Type :Grant Deed Vesting Type :Trust\trustee
* % Owned : 100
*
* < < < ASSESSMENT AND TAX INFORMATION > >
*
Exempt Type
Land :$20, 719
* Structure :$87, 395 Exempt Amount *
* Other Tax Rate Area : 13003
* Total :$108, 114 11-12 Taxes : $2, 302. 90
* % Improved :81
*
*
* < < < PROPERTY DESCRIPTION > > >
*
* Census :Tract: 5078 .06 Block: 3
* Map Grid :832 D7
* Zoning :R1-10 Res Single Family Res-10000 Sf/Du
* Land Use :01 Res, Single Family Residence
* Sub/Plat :Garden Gate Village Add
* Legal :TRACT 783 GARDEN GATE VILLAGE ADDN
* :BOOK 30 PAGE1 30 PAGE2 33 LOT 82
* MLS Area : 18
*
*
* < < < PROPERTY CHARACTERISTICS > >
* Units YearBuilt : 1951
* Total Rms : 6 Bldg SF : 1, 606 EffYearBlt : 1951
* Lot SF : 9, 600 Patio :No
Bedrooms : 3 Porch :Yes Garage Sp
* Bathrooms : 1.00 Useablees: 9, 600 Elevator Garage SF
* Stories : 1 Lot Acres: .22 Lease SF Bldg Cond :Avg
* Dining Rm Lot Dimen:75x128 g
Bld Class : 5.0
* Family Rm : 1 Pool :No Office SF:
S rinkler: Bldg Shape :L-Shape
* Room Fireplace: p Gara eT :None
Rec
* 1stFlr SF: 1, 606 g YP
UtilityRm Sauna
2ndFlr SF: WallHgt
* Water Src Dishwsher: AddtionSF
* Elect Svc Tennis Ct: 3rdFlr SF:
* Gas Svc FrameType:Wood Rental SF:
* Cnt1Ht/Ac:Heat Only
*
*********************************************************************************************
Information compiled from various sources. Real Estate Solutions makes no representations
or warranties as to the accuracy or completeness of information contained in this report.
CITY OF CUPERTINO 1
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20816 fargo dr. DATE: 02/17/2012 REVIEWED BY: bob s.
*VALUATION: $800
APN: BP#:
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PENTAMATION 1 REAP1
PRIMARY SFD or Duplex PERMIT TYPE:
USE:
WORK temp power pole
SCOPE
APPLIANCE/EQUIP TYPE
FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200
100 Amps $44
$44.00
TOTALS:
Elec.Plan Check 0.0 hrs $0.00
Elec.Permit Fee: IEPERMMT
Other Elec.Insp. 0.0 hrs $44.00
NOTE: This estimate does not include fees due to other Departments
(i.e.Planning,
and are onTl Public an estis►nate eContacte De,Sanitarqy rtDor addn'l info.
District,etc. . These fees are based on the re m o rY�FEE MISC ITEMS
FEE ITEMS (['e�e Reco%tion 11-053 Eff z'l%11
FEE Q
F==
PME Plan Check: $0.00
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Administrative Fee: ]ADMIN $41.00
Work Without Permit? o Yes (F) No $0.00
Travel Documentation Fee: 1 TRA VDOC $44.00
Strong Motion Fee:
1 BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00 TOTAL FEE:-=E0
SUBTOTALS: $174.50 $0.00
Revised: 1/19/2012
GENERAL PERMIT APPLICATION
MEP
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE -CUPERTINO, CA 95014-3255
CUPERT{NO (408)777-3228- FAX(408)777-3333- buildinoCcDcupertino.org MISC
❑PLUMBING ❑MECHANICAL ❑ELE CAL ❑MISCELLANEOUS
PROJECT ADDRESS
OWNER NAME, i�q ,(-�/ /PHO E-MAIL
7 0 - ,
STREET ADDRESS CITY, STATE,ZIP FAX
711,1CONTACT NAME PHONE E-MAIL
J/9 .
_ " Q
S ADDRESS CITY,STA ZIP FAX
/0 G� 9 3 _
Pf OWNER ❑ OWNER-BUILDER. ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT 13 ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENS NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME- ) EMAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
�7
ARCHITE GINEER NAME LICENSE NUMBER BUS.LIC#
COMP NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF .DUPLEX ❑ MULTI-FAMMY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK /
r
TOTAL VALUATION: v RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. have read the Description of Work and verify it is accurate. I agree to comply wit all applicable local
ordinances and state laws relating to ction'I auth ves of Cupertino to enter the above-identif d property for inspection pudposes.
Signature ofAppl cant/Agent: Date:
SUPPLEMENT ORMATION REQUIRED OFFICE USE ONLY
23 -TH-E COUNTER
C6
❑ EXPRESS
x
U
W ❑ STANDARD
U
❑ LARGE
4
❑ MAJOR
MEPMJscApp_2011.doc revised 06/21/11