10040017 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10633 MORENGO DR CONTRACTOR:ZIBA CONSTRUCTION PERMIT NO: 10040017
OWNER'S NAME: AMELIA MANZANO
2092 JONATHAN AVE DATE ISSUED:04/05/2010
VER'S PHONE: 4082577534
SAN JOSE,CA 95125 PHONE NO:(408)348-9422
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I— ELECT I— PLUMB r
License Class f3 Lic.#
G I J MECH RESIDENTIAL[_ COMMERCIAL
Contractor Ina +n s`Cr i e,.,Date Z /�/ i o
TOB DESCRIPTION:PANEL UPGRADE FROM 100 AMP TO 200 AMP
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1200
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:37534010.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 1 0 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Igo DA ROM 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 G s4—l� Date:
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by:
9.18. /
Signature Date L4/5-1 D
RE-ROOFS:
V 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: Date:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance Safety Code,Section 25532(x)should I Municipalth the Cupertino rea oreha er d etha ardousand
material.Health
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,I shall J
not employ any person in any manner so as to become subject to the Worker's Owqfr or authorized Writ. Date:
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
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
unify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
i Licensed Professional
9.18.
Date Zt2I a
Signature
G
CITY OF CUPERTINO
PERMIT RECEIPT OPERATOR: patg
5 ITEMS OF 5 COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37534010 . 00
DATE ISSUED. . . . . . . : 04/BSO0002000
RECEIPT # . . . . . . . . .
91
REFERENCE ID # 10040017
SITE ADDRESS 10633 MORENGO DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER AMELIA MANZANO
ADDRESS 10633 MORENGO DR
CITY/STATE/ZIP CUPERTINO, CA 95014
RECEIVED FROM • " ZIBA: MEHRDADNOIN
CONTRACTOR . . . . . . CHP,VOSHLIC # 31120
COMPANY ZIBA CONSTRUCTION
ADDRESS 2092 JONATHAN AVE
CITY/STATE/ZIP SAN JOSE,
CA 95125
TELEPHONE
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC --NEW BAL-
_ ----------
--------
------------- 1. 00 0 .00 1 . 00 0 . 0
1, 200 .00
1BCBSC VALUATION 0 . 00 0 . 50 0 . 00
1BSEISMICR VALUATION 1, 200 .00 0 . 50
1 . 00 42 . 00 0 .00 42 . 00 0 . 00 1.00 42 . 00 0 . 00
JEPERMITFE FLAT RATE 42 . 00 0 . 00
1ERT<200 UNITS
1 . 00 42 . 00 0 .00 42 . 00 0. 00
1TRAVDOC FLAT RATE ---------- ----------
TOTAL PERMIT
----
------0 .00 127 .50 0 . 00
METHOD OF PAYMENT
AMOUNT REFERENCE NUMBER
----------------- ---------------
CHECK 127 . 50 #0569
---------------
TOTAL RECEIPT 127 . 50
t /\ /r,'�ff y�n//////�� 12 ( ti
CITY OF CUPERTINO
CUPEk ANO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # _ Date:
Building Address:
10J.33 Marpr%�So Qr. CLt .r `i,&v%,-3 , CA 01`A
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No �K
HOA: Exterior work onl Yes ❑ No ❑ If es, rovide letter from HOA
Owner's Name: Phone#:
Ame a .Man Z-O..V,-.o
tioS - Z�7-
Phone:ne: 441-08 -�`�8- �`-i �-z-
z �ba
Fax E/o8 -Q7g- 733z—
Contractor License#:6 9615rj
Cupertino Business License#: -Phone: b _ <� ,�Z
Contact: �� 3$
v ehrotca d C.kavosh IFax: S n
Residential Commercial
Job Description:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type:
1-A 1-BII/I1I/V-A ❑ 11/11I B, IV-HT,V-B Sr-1/.LA -
' ❑
Valuation: Square Footage:
� . 0 0
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.buildit reen.or
Revised 07/14/09
. 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 pan ck fee)
IEPERMITFEE Electrical Permit Fee E
1
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 PERMIT
/ TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
IT VDOC Travel &Documentation B
1BUSLIC Business License B
IR 20a 5of5