10010088 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10068 ADRIANA AVE CONTRACTOR:US REMODELERS PERMIT NO: 10010088
OWNER'S NAME: KHAN MEHNAZ 405 STATE HWY 121 BYPASS BLDG A DATE ISSUED:01/20/2010
ER'S PHONE: 4082558614 LEWISVILLE,TX 75067 PHONE NO:(510)887-0300
LICENSED CONTRACTOR'S DECLARATION
\ BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.# 749-W-7
MECH RESIDENTIAL COMMERCIAL
Contractor
I hereby of. a ~ice sed er the provisions of Chapter 9
JOB DESCRIPTION:INSTALLATION OF DANZE VALVE(SHOWER)
(commenc' with Sec n 7000)of Division 3 of the Business&Professions
Code and that my li se 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:$1000
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
permit is issued. APN Number:32620007.00 Occupancy Type:
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 180 DAYS OF PERMIT ISSUANCE OR
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 source regul ions per the Cupertino Municipal Code,Section Issued b '°`X"T "` Date:
9.18.
Signature L Date L�
/ RE-ROOFS:
L OWAR-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)
1,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
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 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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's 772:UCTIfENDING
Compensation laws of California. If,after making this certificate of exemption,1 : 2 C�
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. 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
it nify and keep harmless the City of Cupertino against liabilities,judgments,
L nd expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
graining 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 r ul ions per the Cupertino Municipal Code,Section
9.18. I I Licensed Professional
Signature Date !/ /�
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32620007. 00
DATE ISSUED. . . . . . . : 01/20/2010
RECEIPT ## . . . . . . . . . : BS000009592
REFERENCE ID # . . . : 10010088
SITE ADDRESS . . . . . : 10068 ADRIANA AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER KHAN MEHNAZ
ADDRESS . . . . . . . . . . : 20068 ADRIANA AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1126
RECEIVED FROM JEFF RAINEY
CONTRACTOR SALLY SALEH LIC # 31437
COMPANY . . . . . . . . . . : US REMODELERS
ADDRESS . . . . . . . . . . : 405 STATE HWY 121 BYPASS BLDG
CITY/STATE/ZIP . . . : LEWISVILLE, TX 75067
TELEPHONE (510) 887-0300
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 11000 .00 1. 00 0 . 00 1 . 00 0 . 00
1BPFIXTURE NO OF FIXTURE 1. 00 8 . 00 0 . 00 8 . 00 0 . 00
1BSEISMICR VALUATION 11000 .00 0 . 50 0 . 00 0 . 50 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 93 . 50 0 . 00 93 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 93 . 50 VISA
---------------
TOTAL RECEIPT 93 . 50
CITY OF
y CITY OF CUPERTINO
GENERAL BUILDING
CUPERTINO PERMIT
APPLICATION FORM
APN#,3 0,7 �
Date:
Building Address:
1,nO4:,
Xalr 0 n A
Mailing Address (i different qom building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No a
HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA
Owner's N me: P ne#:
ki
Con c r: P one: ,57 U - ?- 0�o d
77c//n 0 _ �' Fax: S70 -8g,7- 1&211)
Contractor License#: -7 0
Cupertino Business License#:
Contact: Phone:(jVO j P6 7- 0,300
Fax: ��s)
Residential [� Commercial ❑
Job Description:
Da
Building Permit Info:
Bldg ❑ Elect ❑ Plumb C Mech ❑
Type of Construction(Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A F] II/III B IV-HT V-B
Valuation: f i Square Footage:
/ Gq .
Project Size: Express ❑ Standard ❑�Lar e❑ 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.builditereen.org
Revised 07/14/09
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CU PEf�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)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
I
1 ELCPLNCK 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
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1 BUSLIC Business License B
r 5 of 5
Community Development
10300 Torre Avenue
Cupertino CA 95014
F"
Telephone(408)777-3228
CITY OF Fax(408)777-3333
:UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
z D0b 9 k>'?-1 A.J A AVriz-
OWNER'S NAME: K tj,40,q /✓I E f4A)A z PHONE # 5td T_ 05cZ:)
GENERAL CONTRACTOR: �) yr►v��'i r-�. 5 3 ,�L FAX # 510 5?o�?.?-/6/0
I am not using any an subcontractors: I �/v
i ture Date
Please check applicable subcontractors and co ete the following information:
SUBCONTRACTOR BU NESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating I
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper I
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
er/ ac gna Date