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09110103 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10807 LINDA VISTA DR CONTRACTOR:MEHRNAZ YAZDI PERMIT NO:09110103 OWNER'S NAME: MEHRNAZ YAZDI 10807 LINDA VISTA DR DATE ISSUED: 11/18/2009 ER'S PHONE: 4082527681 CUPERTINO CA,CA 950144748 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH F RESIDENTIAL COMMERCIAL F Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: EXTERIOR LATH FOR STUCCO.APPROX 700 SQFT (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:$3000 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 permit is issued. APN Number:35607032.00 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 regulations per the Cupertino Municipal Code,Section Issued byt Daffi'! 9.18. Signature Date RE-ROOFS: rJ 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: 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) I,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. 1 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 1 certify that in the performance of the work for which this permit is issued,1 shall Health&Safety Co e,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owner or u hori ed t: Compensation laws of California. If,after making this certificate of exemption,I dr Date:IKE 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. CONSTRUCTION LENDING AGENCY I hereby affinn 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 i iify and keep harmless the City of Cupertino against liabilities,judgments, C, ,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply 1 understand my plans shall be used as public records. with all non-point source regulations p the Cupertino Municipal Code,Section 9.18. Licensed Professional Date Signature" CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35607032 . 00 DATE ISSUED. . . . . . . : 11/24/2009 RECEIPT #. . . . . . . . . : BS000009268 REFERENCE ID # . . . : 09110103 SITE ADDRESS . . . . . : 10807 LINDA VISTA DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MEHRNAZ YAZDI ADDRESS . . . . . . . . . . : 10807 LINDA VISTA DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4748 RECEIVED FROM . . . . : MEHRNAZ YAZDDI CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : MEHRNAZ YAZDI ADDRESS . . . . . . . . . . : 10807 LINDA VISTA DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4748 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 000 . 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 3, 000. 00 0 .50 0. 00 0 . 50 0 . 00 1STUCOAPP SQ FEET 700. 00 475 . 00 0 . 00 475 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 476 .50 0 .00 476.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 476 .50 VISA --------------- TOTAL RECEIPT 476 . 50 CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# / Date: 2-00J Building Address: i,0 �� 7 t i o d a Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA Owner's Name: r Phone • yoi-c - - Contractor: Phone: Fax: Contractor License#: j� Cupertino Business License#: Contact: dho-v4-Ic-d Phone: C) YY q 3 l Fax: Residential ] Comm rcial El Job Description: X�z v;v Y L--u` .. -� LL 0 Q Building Permit Info: Bldg ® Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B D--' Valuation: .40 Square Footage: Le-55 4( w, '7©o 5a t b Project Size: Express ®---S-tandard ❑ 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.buddit2reen.org Revised 07/14/09 CITY OF CUPERTINO CIT'OF GENERAL BUILDING APPLICATION CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM �a a 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) IEPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE 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 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B 5 of 5 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 work (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' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be erformed ..................................................................................................................................................................................... I declare under penalty of perjury thIve is true and correct. I have read and understand the Owner-Builder Information(reverse Property Owner's Signature. Date: / / Job Address: �C�c�� 7 G�%'�A 5% `moi ` Permit# Cvpel�j 1� v t Any changes to the information Rrovided on this form shall be submitted to the City of Cupertino Build Department.