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12110008 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22717 SAN JUAN RD CONI'RACI'OR: HOMEOW'NE'R. PERMIT NO: 12110008 OWNER'SNAME: IIOMA&MEI IRDAD MOJGANI IN DATE ISSUED: 11/02/2012 OWNER'S PI IONS: 4084822628 CUPERTINO,CA 95014 PIIONENO: ❑ LICENSED CONfRACPOR'S DECLARATION .1011 DF,SCRIPI'ION: RFSIDEN17AL COMMERCIAL License Class Lie.p TEMPORARY POWER POLE Contractor Date hereby affirm that 1 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 performance of the work for which this permit is issued. Sq.Ft Flour Area: Valuation:$500 1 have and will maintain Worker's Compensation Insurance,as provided for b% Section 3700 of the Labor Code,for the performance of the work for which this ,U'N Number:34217025.00 Occupancy Tcpc: permit is issued. APPIACAN I'CERTIFICATION I cenify thin I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. l agree to comply with all city and county ordinances and stale 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 propeny for inspection purposes. (We)agree to save 180 D YS FROM FAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, S / costs,and expenses which may accrue against said City in consequence of the 1 • Z' granting of this permit. Additionally,the applicant undemands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Rf:ROOFS: Signature Date All roofs shall be inspected prior to rmy roofing material being installed. If a roof is installed without first obtaining:"inspection,I agree to remove all new materials for inspection. rN/ 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,ormy employees with wages as their sole compensation, 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 HAZARDOUS MATERIALS DISCLOSURE construct the project(See.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 5505.25533,and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Ilealth&Safety Code.Section 25532(a)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 contaminants as defined by the Bay Area Air Quality Mn nagement District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and I has,e and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or nuthorized ngent: ��Date: . I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a consimcdon lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. w'ork's for which this permit is issued(Sec.3097,Civ C.) 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, A RCI I ITECr'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 — G +pate 1Z CITY OF CUPERTINO cc Q FEE ESTIMATOR - BUILDING DIVISION 42 �jDo cc ADDRESS: 22717 san Juan rd. DATE: 11/02/2012 REVIEWED BY: larrys APN: BP#: `VALUATION: $500 *PERDIIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARYPENTAMATION USE: SFD or Duplex PERIIIITTI'PE: 1REAP1 WORK tem Ower pole SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES 'Temporary.Power 1ERT<200 200 Amps $45 TOTALS: $45.00 Mech. flan Check Plumb.Plon Check Elec. Plan Check 0.0 1 hrs $0.00 blech. Penuit Fee: Plumb.Permit Fee: Elec..Permit Fee: I EPERAIIT Other,tfrch. Insp. Other Plumb Insp. Other Elec. Insp. hrs $45.00 0.0 ;Vlech.Insp.Fee: Phunh.ht..p. Fee: EICc.dtup. Fee: NOTE: This estimate does not include fees due to utter Departments(i.e. Planning, Public If'orks, Fire,Sanitaq,Server District,School District, etc. . These ees are based on the prelinzinan information available and are only an estimate. Contact the Dept for addn't info. FEE ITEMS (Fee Fee 11-053 EB: 7/1/12) FEE QTY/FEE MISC ITEMS Plan Chcelc Fee. Suppl. PC Fee PME Plan Check: $0.00 Permit Foca: Suppl. Insp Fee PME Unit Fee: $45.00 PME Permit Fee: $45.00 Construction Tai: Administrative Fee: IADMIN $42.00 Work Without Permit? Yes. Q No $0.00 Advanced Planting Fces: Travel Documentation Fee: ITRA PDOC $45.00 Strone Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg, Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $178.50 $0.00 TOTAL FEE: $178.50 Revised: 10101/2012 GENERAL PERMIT APPLICATION M E d • .. COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 • PAX(408)777-3333 • builcinacncuoerino.Dra ❑'JPIXISIING ❑MECHANICAL LECTRICAL ❑MIISSCELLANEOUS PRC):-CT ADDRaSS 0Z, Z ( I /) SI.VVt 'V%l• �+'' ./ �� r /— 0.25 OWNER NAME r mo, I PHONE [�D _ / C�'�/,,'/I EM/.IL'�i mQ•�U VII�jnU({�I I. �'h 3TR.cc"7ADDRESS 'Z �:3'Ia �/I//,�,I �1..�. CITY. STA'fF,7.IP /, T Dpi' 13G/jSCfi- ?bald `"X CONTACT NAME G2S �//i�+ - PHONE (/`G E-MAIL ST:L-c—TADDRSS k ClY.STAT-, ZT FAX OWNER ❑ OWNER-BUaMEIt ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AG rr. ❑ ARCFTlr ❑ ENGD.— ❑ D1�r^L. OPFA ❑ T9UhT CONTRACTOR NAME /�/J (\ LCENSE NVNSER UCENSE TYFE I BUS.LICF COMPANY NAME -cc-MAM FAX STR1_T ADDRESS CITY,STAT;L'P 77�� ARCH.—I- /ENGINFs7i NAME I LICENSE NUN-M7R 13US.LIC# COMPANY NAM.. E-NI&M I FAX STTLEFT ADDRESS CITY',STATE-ZIP ?HON_ USE OF ❑SFDmoUP= ❑ MULTI-FAMRY PROJECT IN WILDLAND ❑ Y-S I PROJECT IN ❑YE; I ISTF BLOGAN ❑ YES BUMMING: ❑COMM.JtC URBAN INTERFACE AR&A ❑ NO FLOOD ZONE ❑NO MCHLEF HOMET ❑NO DESCRIPTION OF WORX r. �p TOTAL VALUATION: RECEIVED BY: By my signature below,I certify w each of the following: I am the propery owner or authorized agent to act on the property own 's behalf. 1 have read this application and the in`ormatien I have provided is coaecL I have read the Description of Wo$t and verify it is actanetc. 1 age to to comply with all applicable local ordinances and state laws relating to building construction. I autborize representatives of Cupertino to enter the above-identified prone,,—.Y for inspection puijposes. Signature of Applicant/Agent: - C Data: SU-PPLENff.NTAL T&1F.0V-1vtATION REQ1jaED OFFICE USE ONLY y ❑ OWER-THE-COUNTER i ❑ EXPRESS ❑ STANDARD U < ❑ LARGE ❑ MAJOR T�CPMuc4pp_2011.doc reused 06/21/11 -