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10040120 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10637 GASCOIGNE DR CONTRACTOR:HAMID SHOJAEE PERMIT NO: 10040120 OWNER'S NAME: HAMID SHOJAEE 10637 GASCOIGNE DR DATE ISSUED:04/20/2010 BIER'S PHONE: 6507404899 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG[_ ELECT r— PLUMB License Class Lic.# MECH f— RESIDENTIAL r COMMERCIAL Contractor Date JOB DESCRIPTION:ADD 8 RECEPTCLS,2 FLUORECNT LIGHT FIXTR ON I hereby affirm that I am licensed under the provisions of Chapter 9 CEILNG,2 MOTIN SENSR LIGHTS,I GARGE OPNER OUTLET,I (commencing with Section 7000)of Division 3 of the Business&Professions OUTDOOR WTR PROOF OUTLT@ STREETSDE&SHEET ROCK Code and that my license is in full force and effect. 4—r Pi c('�0.�- d-ZD f U 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. 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 Sq.Ft Floor Area- permit is issued. APPLICANT CERTIFICATION APN Number:37528017.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 1 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 180 DAY OM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: I/ J-1-2-0 —1(] Date: Signature Date V J OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health& afety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I e or authorized agent: / become subject to the Worker's Compensation provisions of the Labor Code,I must Date:.— forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address and expenses which may accrue against said City in consequence of the granting of this perm.t.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-points urce regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature �0//() Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37528017 . 00 DATE ISSUED. . . . . . . : 04/20/2010 RECEIPT #. . . . . . . . . BS000010219 REFERENCE ID # . . . : 10040120 SITE ADDRESS 10637 GASCOIGNE DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER HAMID SHOJAEE ADDRESS 10637 GASCOIGNE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM HAMID R SHOJAEE CONTRACTOR LIC # *OWNER* COMPANY HAMID SHOJAEE ADDRESS 10637 GASCOIGNE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ---------- --------- 1BCBSC VALUATION 400 .00 1. 00 0 .00 1 . 00 0 . 00 1BREMFIXT NO. FIXTURES 1 . 00 63 . 00 0 .00 63 . 00 0 . 00 1BREMRECEP NO. OUTLETS 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 1BSEISMICR VALUATION 400 . 00 0 . 50 0 . 00 0 .50 0 . 00 1EPERMITFE 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 190 . 50 0 . 00 190 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ------- CREDIT CARD 190 . 50 MC --------------- TOTAL RECEIPT 190 . 50 U C CITY OF CUPERTINO CUPEI�TINO GENERAL BUILDING PERMIT APPLICATION FORM APN # ._-7 Date: Building Address: o 6 y 6,4 s C 01 G N _D 2 Mailing Address (if different from buildi" address): Are Hazardous Materials being used as part of this project? Yes ❑ No ❑ HOA: (Exterior work only) Yes ❑ No XIf yes, rovide letter from HOA Owner's Name: Phone#: CP 6 _-7 C/o Contractor: O( C Phone: Fax: Contractor License#: Cupertino Business License#: Contact: Phone: Fax: Residential Commercial ❑ 2 � Wil-iti� �� L�J�c7' Job Description: CAI �_ � C�i►�� $ x C' CI Rc CEP rPcldS � drys 0 � Cep/�� ^JAI q Z x r10are cems{ 11gAt F x Y)l o Azo."a S20SOR li 4 S 3 * I J o P e^ o✓ O u-t /e theo-t S i c L2 _ ^ 1di�g x oatdoo r U/ te,- ou�� o� ! 5 Cd✓�� / / 74 Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction(Usage Class): Occupancy Type: 1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V- Valuation: Square Footage: 02 s � Project Size: Express Standard ❑ 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.bufldit2reen.org Revised 07/14/09 CITY OF CUPERTINO Cin OF GENERAL BUILDING APPLICATION CUPEf�T1NO FEE SCHEDULE Quanti 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) l 1EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK 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 EPRMIT / B ES 1BSEISMICR Seismic Residential r B 1BSEISMICO Seismic Commercial 1TRAVD0C Travel &Documentation B 1BUSLIC Business License B 5 of 5