12050080 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22286 HARTMAN DR CONTRACTOR:BATH FITTER PERMIT NO: 12050080
NORTHERN CALIFORNIA
OWNER'S NAME: KIADEH MANSUR B 2118 ZANKER RD DATE ISSUED:05/07/2012
OWNER'S PHONE: 4083138458 SAN JOSE,CA 95133 PHONE NO:(408)834-1111
/� LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL CO%11NERCLU,
License Clasa✓ '4 1 D Lica /U 3 <59 INSTALL NEW VALVE IN BATHTUB
Contractor IAVDaleL Z-
1 hereby e m tnl I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty or 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
performance of the work for whichthis permit is issued. Sq.FI Floor Area: Valuation:$845
I have and will maintain Worker's Compensation Insurance,as prov' d for b
Section 3700 ofthe Labor Code,for the performance of the wor rwhi thi APN Number:32613085.00 Occupancy'I'ype:
permit is issued-
APPLICANT CERTIFICATIO
I certify that I have read this application and state that the a anon is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 1 0 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned properly for inspection purposes. (We)agree to save 180 DAY M LAST CALLED INS?E TION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ,�j../�/
costs,and expenses which may accrue against said City in consequence of the yrf /2
granting of this pc it. Additionally,the applicant understands and will comply Issued by: U[ Date:
with all non-poin sourc r ulations per the Cupertino Municipal Code,Section
9.18.
_ RF,-ROOFS:
Signature ZZZ�_
Date �z 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
1 hereby affirm that 1 em exempt from the Contractor's License Lew for one of Signature of Applicant: Dale:
the following two reasons: AL1,ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sce.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIAI S DISCLOSURE,
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 255341. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should 1 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 contaminantsas defined by th Bay
rmArea Air Quality Management District 1
perfoance of the work for which this permit is issued. will maintain compliance with th Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Seeti 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent•. Dale:
I certify that in the performance of the work for which this permit is issued.I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGF.NCV
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a conshruction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
1 certify that 1 have read[his 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
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 regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32613085. 00
DATE ISSUED. . . . . . . : 05/07/2012
RECEIPT #. . . . . . . . . : BS000016743
REFERENCE ID # . . . : 12050080
SITE ADDRESS . . . . . : 22286 HARTMAN DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KIADEH MANSUR B
ADDRESS . . . . . . . . . . : 22286 HARMAN DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1020
RECEIVED FROM . . . . : JOE NANNETTI
CONTRACTOR . . . . . . . : BATH FITTER NORTHERN CALIFORNI LIC # 31358
COMPANY . . . . . . . . . . : BATH FITTER NORTHERN CALIFORNI
ADDRESS . . . . . . . . . . : 2118 ZANKER RD
CITY/STATE/ZIP . . . : SAN JOSE, CA 95133
TELEPHONE . . . . . . . . : (408) 834-1111
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- -------- --
-ADMIN HOURS 1.00 41.00 0.00 41.00 0. 00
1BCBSC VALUATION 845.00 1.00 0. 00 1 .00 0 .00
1BPFIXTURE NO OF FIXTURE 1. 00 9. 00 0. 00 9 .00 0 . 00
1BSEISMICR VALUATION 845 .00 0 .50 0. 00 0 .50 0 . 00
1PPERMITFE FLAT RATE 1.00 44 . 00 0.00 44 .00 0. 00
1TRAVDOC FLAT RATE 1.00 44 . 00 0.00 44 .00 0. 00
---------- ---------- ----- ----- ----------
TOTAL PERMIT 139. 50 0 . 00 139.50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
-- --------------- --------------- --------------------
CREDIT CARD 139.50 visa
---------------
TOTAL RECEIPT 139.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- ------ ----- ------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING 512 FINAL HANDI-CAP