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09100181 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10123 BRET AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09100181 OWNER'S NAME: MICHEL KHOUDERCHAH DATE ISSUED: 10/27/2009 ER'S PHONE: 4082524458 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class /L^1© Lic.# [S MECH f— RESIDENTIAL f— COMMERCIAL Contractor S S le 0 C[c C Date /0 —27—O Cf JOB DESCRIPTION:PANEL UPGRADE FROM 125AMP TO 200AMP 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 my 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 Sq.Ft Floor Area: Valuation:$1800 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:37511025.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.1 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 DAYS FROM 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 granting of this permit. Additionally,the applicant understands and will comply Issued Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Date ^ 7'O Signature L,,;,L,,;, �� /O2C( RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is �. OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Signature of Applicant: Date: 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(Sec.7044, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE 1 hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the declarations: California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material. performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will 1 have and will maintain Worker's Compensation Insurance,as provided for by maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534. permit is issued. I certify that in the performance of the work for which this permit is issued,I shall Owner aut4orized agent: not employ any person in any manner so as to become subject to the Worker's Date:/e— Z 7�� Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY forthwith comply with such provisions or this permit shall be deemed revoked. 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.) APPLICANT CERTIFICATION Lender's Name I certify that I have read this application and state that the above information is Lender's Address 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 rmify and keep harmless the City of Cupertino against liabilities,judgments, 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: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 37511025 . 00 DATE ISSUED. . . . . . . : 10/27/2009 RECEIPT #. . . . . . . . . BS000009048 REFERENCE ID # 09100181 SITE ADDRESS 10123 BRET AVE SUBDIVISION CITY CUPERTINO, IMPACT AREA . . . . . . OWNER MICHEL KHOUDERCHAH ADDRESS . 10123 BRET AVE CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM SERGIO MENA CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- - 1BCBSC VALUATION 1, 800. 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 1, 800 . 00 0 .50 0 .00 0 . 50 0 . 00 1BUSLIC FLAT RATE 1. 00 114 .00 0 .00 114 . 00 0 .00 1EPERMITFE FLAT RATE 1. 00 42 .00 0 . 00 42 . 00 0 . 00 1ERT<200 UNITS 1. 00 42 . 00 0 . 00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 ------0_00 ---------- ---------- ---------- TOTAL PERMIT 241 .50 0.00 241. 50 0 .00 METHOD OF PAYMENT AMOUNT --REFERENCE NUMBER ----------------- --------------- CHECK 241 .50 #1255 --------------- TOTAL RECEIPT 241 .50 f 06, I #` CITY OF CUPERTINO CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# c?;7 �_ , O 2 Date: Building Address: /O /z--s F3ye -� Av<z- Ouverk� wfa QQ, 9 .-56 / y Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: Exterior work only) Yes ❑ No If es, provide letter from HOA Owner's Name: Phone#: zCih � cggLv, 2S2, -- g415 Contractor: r Phone: Ltoj- Za 2,-- 5S-S 4 S s, K olaci C- Fax: 08 53Z-JSZ6 Contractor License#: C —/C) g 4 0 3 0 8 Cupertino Business License#: Contact: Phone: gots' 2.o 2--ss S G Ya�.�d 2 NCS Fax: Residential Commercial Job Description: Q� L ,jQc�`ra-& Q FWtP4 t?-SA -1-0 OOOA Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-B — Valuation: Square F otage: Project Size: Express Eg----§tandard ❑ 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.buildit reen.or Revised 07/14/09 K CITY OF CUPERTINO CITY OF GENERAL BUILDING APPLICATION CUPEi�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1WINMEWSTR New Window-structural shear B wall/masonry (includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCIC Stand Alone Mechanical Pln Ck(hrly) M IPLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT / TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B IT AVDOC Travel &Documentation B 1BUSLIC Business License B / '`� 7 5 of 5 Community Development 10300 Torre Avenue a. Cupertino CA 95014 Telephone(408)777-3228 ,CITY OF ' Fax(408)777-3333 -UPEkTINO Buildin De artment JOB ADDRESS: PERMIT # /0/ ?-3 yc� Cv dr�-LNO OWNER'S NAME: A I un,Q I L V." � r-..) PHONE # qOt 20'2-r.SS56 GENERAL CONTRACTOR: S Sr C Imo -' e FAX# 1foC-^ 53Z--/-5Z45 I am not using any subcontractors: 27-6 Signature Datt e 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 Z 7-40 Date Owner/Contractor Signature