10020001 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21810 SAN FERNANCO AVE CONTRACTOR:VAROUJ BAGHDASARIAN PERMIT NO: 10020001
OWNER'S NAME: VAROUJ BAGHDASARIAN 22757 STEVENS CREEK BLVD DATE ISSUED:02/01/2010
IER'S PHONE: 4084065678 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION C� r h
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.# r—
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL 2ND PG&E ELECTRIC&GAS METER FOR THE
(commencing with Section 7000)of Division 3 of the Business&Professions SIDE
Code and that my license is in full force and effect. UNIT OF THE MAIN HOUSE
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: Valuation:$800
permit is issued.
APPLICANT CERTIFICATION APN Number:35715058.00 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,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature� Date 7 /t
v 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
1,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,
Business&Professions Code) Signature of Applicant: Date:
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&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
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&Safety Code,Sections 25505,25533,and 25534.
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 mustOwner or horized agent:
01
forthwith comply with such provisions or this permit shall be deemed revoked. !v Date: Z �
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
'mnify 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 permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature �^ Date 2 z��� Licensed Professional
CITY OF CUPERTINO
7 ITEMS OF 14 PERMI" RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Bllz: Lot:
APN . . . . . . . . : 35715058 . 00
DATE ISSUED. . . . . . . : 02 /01/2010
RECEIPT # . . . . . . . . . BS )00009658
REFERENCE ID # . . - : 10 )20001
SITE ADDRESS . . . . . : 21310 SAN FERNANCO AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : VAROUJ BAGHDASARIAN
ADDRESS 22757 STEVENS CREEK BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : VAROUJ G BAGHDASARI
CONTRACTOR LIC # *OWNER*
COMPANY . . . . . . . . . . : VAROUJ BAGHDASARIAN
ADDRESS 22757 STEVENS CREEK BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------
1BCBSC VALUATION 800 .00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 800 . 00 0 .50 0 .00 0 . 50 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
1PGASRES OUTLETS 1.00 63 . 00 0 .00 63 . 00 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 232 . 50 0 . 00 232 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 465 . 00 #3849
---------------
TOTAL RECEIPT 465 . 00
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. All the work authorized by this permit
B. — A portion of the work
C. None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the worl. (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' comp 2nsation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
................................................................................. ...................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature:
GG' � Date:
Job Address: /
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Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
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CITY OF C PERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# 3577-
577- /S'- a 5-5,L,"-? 0 Date: V I/Z-O/V
Building Address: / 9/0 FernaH �{d ave . C(,lpPr f llt p
Mailing Address (if different from buil ing address):
2 veo C'r�k Cu �r�YH o CA Oro I
Are Hazardous Materials being used as part of this► project? Yes ❑ No
HOA: Exterior work only) Yes ❑ No ffl—If yes, provide letter from HOA
Owner's Name: Phone#:
var'ou l�daSa�� ?a� 68 q06 -56 -7e
Contractor: UPhone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial El
Job Description: //V S�i4 �� Zn �G E . �Q G7�1 C ON01 qa-r
Building Permit Info:
Bldg Elect ®-- Plumb E- Mech ❑
Type of Construction(Usage Class): Occupancy Type:
1-A5 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-:3 Q- V -`*
Valuation: 4 �v v Square Footage:
Project Size: Ex ress Eq` Standard ❑ Large__::] Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicably;, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgr�en.or
Revised 07/14/09
CITY OF (:UPERTINO
Cin 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
1WINREP Replacement windows/sliding glass B
door (ea 3 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry (includes plan ck fee)
I EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
/ 1PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1 PLMBLNCK 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:Zesidential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
1BUSLIC Business License B
E1-r <: 1
5of 5
M.Indoor Air Quality and Finishes
1-Ilse LOAWVOC PAR,4 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low*VOG A 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal Ali EVowdl' 6hoadvrW 4 IAQ/Health pts y=yes 0
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0
N.Flooring
1.Select FSC Certified Wood Flooring 3 Resource pts y=yes 0
2.Use Ra*#y Renewable Flooring Materials 1 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles l Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor l Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs l Resource pts y=yes 0
0 !
Total Points 1 1401 130 57
Total Points Project Received: 0 0 0
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