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11040033 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21860 TERRACE DR CONTRACTOR:MASTERSERV INC PERMIT NO: 11040033 OWNER'S NAME: FARZAD HAGHIGHI 560 LIBRARY ST DATE ISSUED:04/06/2011 OWNER'S PHONE: 4088737871 SAN FERNANDO,CA 91340 PHONE NO:(800)806-7674 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r License Class & ,Lic.# MECH RESIDENTIAL COMMERCIAL Contract Date _ I hereby affirm tha am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPIPE IN COPPER,NO FIXTURE REPLACEMENT (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 performance of the work for which this permit is issued. Sq,Ft Floor Area: Valuation:$9200 1 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:35625001.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above infoffnation s correct.I agree to comply with all city and county ordinances and state laws rel ting PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point urce reg er the Cupertino Municipal Code,Section Issued by,/G� � Date. 9.18. L Signatur Date RE-ROOFS: OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the 1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. I certify that in the performance of the work for which this permit is issued,I shall I N. not employ any person in any manner so as to become subject to the Worker'sOwn ge t: Compensation laws of California. If,after making this certificate of exemption,I ate: become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address 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 c- - and expenses which may accrue against said City in consequence of the ig of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. wILo all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35625001. 00 DATE ISSUED. . . . . . . : 04/06/2011 RECEIPT #. . . . . . . . . BS000013101 REFERENCE ID # . . . : 11040033 SITE ADDRESS . . . . . : 21860 TERRACE DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER FARZAD HAGHIGHI ADDRESS . . . . . . . . . . : 21860 TERRACE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : MASTERSERV, INC. CONTRACTOR . . . . . . . : GEORGE ANDERSON LIC # 30854 COMPANY MASTERSERV INC ADDRESS 560 LIBRARY ST CITY/STATE/ZIP . . . : SAN FERNANDO, CA 91340 TELEPHONE . . . . . . . . : (800) 806-7674 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1.00 78. 00 0.00 78 .00 0.00 1BCBSC VALUATION 9,200. 00 1.00 0. 00 1.00 0. 00 1BPVENT UNITS 1 . 00 40.79 0. 00 40.79 0. 00 1BSEISMICR VALUATION 9, 200 .00 0. 92 0.00 0. 92 0. 00 1PPERMITFE FLAT RATE 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 204 .71 0.00 204 .71 0. 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 506 GAS TEST 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21860 terrace dr. DATE: 04/06/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $9,200 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1 RPDP USE: PERMIT TYPE: WORK re-pipe no fixture replacement. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Area 1 PREPPIPE 1 # $42 TOTALS: $42.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. 0.0 hrs $42.00 NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 09-051 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $42.00 PME Permit Fee: $42.00 F717 Work Without Permit? 0 Yes (F) No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Strong Motion Fee: IBSEISMICR $0.92 ( , Select an Administrati e Item Bldg,Stds Commission Fee: IBCBSC $1.00 1� SUBTOTALS: $127.92 $0.00 TOTAL FEE: $127.92 Revised: �1 '� i Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 C O P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 'L C� v t.oC Se PERMIT ZZQ OWNER'S NAME: PHONE# - GENERAL CONTRACTOR: BUSINESS LICENSE# 3 C> p ADDRESS: CITY/ZIPCODE: *Our municipal code requires all busi esses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRAC HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. % I am not using any subcontractors: L ignature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum /Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•building cDcugertino.org MISC CUPERTINO PLUMBING ,J MhCHANICAL i -LECTRICAL ❑MISCELLANE(O�US PROJECT ADDRESS ' / 77�"N# _„� / 1 OWNER NAME V PHONE E-MAIL STREET ADDRESS (' ` S[X�^--•tt �� •V'T�1` C FAX CONTACT NAME ` C Pq 0 Z Z E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRAC OR NA E LICS SE NUM C LICENSE TYPE BUS.LIC# �&Com/ �v l / COMPANY NAME E-MAIL FAX STREET ADDRESSCITY STATE,ZIP PHONE --cU C 6 J5 Ig o 5- ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE `JSE OF SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORKr r� t i TOTAL VALUATION: 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. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to ilding con I authority representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of ApplicandAgent: Date: SU LEM AL INFORMATION REQUIREDoiusoNlY , aYr-R salraurlTx a i S EEXPRES& ...,t. I�..sTAIYDnxri ❑ ;MAJOR MEPMiscApp_2011.doc revised 03/16/11