07110038 CTTY OF CIiPERTINO > F ' ` ' '
BUILDING DIVISIOh PERMIT ���R���CT�. ��������� �
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BUILD(NG ADDRESS: PERMIT NO.
6021 SHADYGROVE DR LOS GAT�S AIRE, INC 07110038 .
.JER'S NAME: �� �� DA �
MEHR TARIQ 84 BROA�WAY 11/07/2007
PHONE: SANITARY NO. CONIROL NO.
(408) 3�9-5191
ARCHI7ECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
� 0 0 �
u p � LiCENSED CONTRACI'OR'S DECLARATION
V� I hcrcby aflicm tlut I am liccnscd undcr provisions oC Chaptcr 9(eommencing Job Description
�� a wi�h Scction 7000) of Division 3 of thc Business and Profcssions Codc, and m licensc is F C D A I R HTG S Y S W/ ENRGY SUNCi PROD MO D# HV 7 0
� y in full foice and elfect. ��' a y l�
� z[.icenu Class �t ��• x &NOR I T Z
��, � Datc ARCHffEGTS DECLARA770N TNKLS 0 5 3 3 BO I LER
;� a
U 1 undcrstand my plans shall be wcd u public records
�
; �. y Liccnsed Rufcssional
� y � OW NER-BUILDER DECLARATION
� <� I hcrcby afCirm that 1 am raccmpt from �hc Can�raaor's Licensc Law far thc
L O O following rcason. (Sccaon 7031.5, Busincss and Profcssions Ca1c: Any city or county
K �i which requiccs a pcm�it w cnnswc4 alter, impmvc, dcmolish, or mp�ir any swcmm
y`� prior W i�s issuance, alsu requires ihe applicant for such pertnit to file a signed s�atement
�_ � that hc is liccnscd pursuant to thc provisions o[ thc Conuacwr's Liccnsc Iaw (Chaptcr 9 � iq. Ft. Floor Area Valuation
y I- $ (commcncing wi�h Scction 7000) of Division 3 of Ihc Busincss and Profcssions Cadc) or $16 0 0 0
y �.. thu he ia emmpt therefrom and the basis for ttie allcgcd eumption. Any violation of
Section 7031.5 by arty applicant (w a permit su6jecu �he applicant to a civil pcnalty of Number Oeeupaney Type
not morc �han five hundred dollars (5500� 3 7 5 4 0 0 0���
❑ I, u owner oCtNe propaty, a my empioyces with wages as �he'v sok compensation,
will do �he work, and ihe steuctwe is not intended or ofTeted for sale (Sec. 7044. Business
and Professions Code:'Ihe Contcactw's Lianse Law does not appiy w an owner ot Required Inspections
property who builds or impmves thercan, and who does such work himselt or ttuough his
own employces, providcd that such improvemenu are not imended or oRered for sala tf.
however, the building or improvemmt ia sold within one year of complcGon, the owner
builda will have �he burden o[ proving �hat hc did no� build or improvc for puryose ot
salc.).
� I, as owner of the propeny, am exclusivoiy conuacting wiW Iicensed rnnvactors W
wnsuuct the pmject (Sec. 7044. Businw and Professions Cade:)'fie Coavacwr's Li-
cense I.�w docs not apply �o an owner of propeny wha 6uilds or improves thereon, and ,
who convacLt tor such piojects wiUi a comractar(s) licensed pursuant to the Convactor's
License Law.
1 am exempt under Sec. , B k P C for this reuon
_ .+nv Date
WORKER'S COMPEAISAT70N DECLARATION
I heceby �rm under penalty o[ pe�jury one o( the following declarations:
❑ I hsve and will mainuin a Cenificate of Consent to self-insure Cor Workcrs Compen-
ution, ss providcd for by Secdon 3700 of �he Iabor Code, far the petfortnancc oC Wc
work far which this pertnit is issued.
❑ I have and will mumain Workcr's Compensation lnsunnce, u�equired by Scction
3700 0[ the Labor Code. Car the performance of the wrork for which �his permi� is issued.
My Worker's Co Insunnce nrtier and Policy number aie:
Cartier.�CT t('� C�[�� M(7��4o1�FjyNo.: C g��`L
CERTIFICATE OF OR FROM WORKE S'
COMPENSATION 1NSURANCE •
(Ihit scction need not bc complctcd if tAe pe[mit is �or anc hundred dollus (5100)
or Icu) '
i ceni[y Ihnt in t6c performancc of thc work for which Ihis pertnit is istucd, [ shall not
employ any persan in any manncr so u w becomc subject to the Workcrs' Compensation
Laws of Califomia. Dalc
Applicanl
NOTICE 7'O APPLICANT: if, af�cr making ihis CertiGca�c of Excmption, you should
bccome subjcct w the Worker's Compcnsation pmvisions of the Cabor Codc, you muu
� O forthwilh comply with such provisions or this pecmi� shall be dcemed awoted.
� '"'' CONSTRUCI70N LENDING AGENCY
(� ►�-� 1 hcroby a1Trtn Ihat thcn is a consuuctian Icnding agcncy for ihc per[urtnancc u(
�� thc work fur which this permit is is�ucd (Scc. 7097, Civ. C.)
W� Q L.endec's Namc .
] z Lcnders Address
V 0 1 certifY Ihat I havc read �his applicuion and sutc thu ihc above infamatiun is
w�"' corten. I agree w comply with all city and county oceiinances and sute laws reladng w
0 U building consuuction, and hc�eby authori�e ecpresenutivcs of ihis city W cntcr upan thc
w ahove-mcntioncd propcny for inspccuon purposes
(Wc) asree �o save, indcmnify and kecp humless �he Ciq of Cupenino against
�,,,� � IiabiliUu, judgmcnLS, cosLS and expensea which may in any way accruc againat said City
V z in consequence of thc gnnting of this permi�
�"" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ' � '��
SOU � GULATiONS �
`.'�1C L���: ( �� Z ��/ Re-roofs /���/�
Signuurc of ApplicanUC tor Datc
OUS MKfERIALS DISCLOSURE Type of R�>of �
�It Ihc applicant or fuuuc building occupant storc or handlc harardous ma�cri�l
�cfincd by the Cupertino Municipal Codc. Chaptcr 9.12, md [he Heal�h and SaCety
�. Scction 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs �No
Will thc applicant or future building cecupant usc cquipmcnt or dcviccs which
If a roof is installed without first obtaining an inspection, I agree to remove
emi� harardous air conuminan�s u dcGncd by �he Bay Area Air Quality Managemcnt all new m<<terials for inspection.
District?
❑ �'a ��
f
1 havc ccxf Ihe ha�a�dnus maicrials �equiremcnLC unJct Chapter 6.95 of ihc Calitor-
nia Hcalih & Safc�yCodc, Sections 25505.25533 and 25534.1 undcrstand ihaz iCthc building
docs not curtcntly havc s �enan4 i1�at it is my rcsponsibiliry to noufy thc accupant of �e
rcyui p ' �'�� whi mus� bc mel prior uance of a Certifica � ra��P�ry. Signature ��f Applicant Date
c� '� �' �� �'�-'"� All roof coverings to be Class "B" or better
Owncr or authori�ed a m ���
CITY OF CUPERTINO
8 ITEMS OF 8 PERMI'I' RECEIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk.: Lot:
APN ......... 37F40002.00
DATE ISSUED.......: 11/07/2007
RECEIPT #.......... BSC00003190
REFERENCE ID # ...: 07110038
SITE ADDRESS .....: 60�1 SHADYGROVE DR
SUBDIVISION .......
CITY .............. CUF'ERTINO
IMPACT AREA .......
OWNER ............. ME�[R TARIQ
ADDRESS ..........: 60�1 SHADYGROVE DR
CITY/STATE/ZIP ...: CUF'ERTINO, CA 95014
RECEIVED FROM ....: LO:� GATOS AIRE, INC
CONTRACTOR .......: PALrL E. BIBER LIC # 28969
COMPANY ..........: LO:� GATOS AIRE, INC
ADDRESS ..........: 84 BROADWAY
CITY/STATE/ZIP ...: LO:� GATOS, CA 95030
TELEPHONE ........: (4(�8) 399
FEE ID UNIT QUANTITY ��'IOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 1.00 34.86 0.00 34.86 0.00
BREMFURN NO UNIT 1.00 14.31 0.00 14.31 0.00
BSEISMICRE VALUATION 16,000.00 1.60 0.00 1.60 0.00
EPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
MPERMITFEE FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
PPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
PRWHEATR UNITS 1.00 24.48 0.00 24.48 0.00
TRAVDOC FLAT RATE 1.00 40.79 0.00 40.79 0.00
--�-------- ---------- ---------- ----------
TOTAL PERMIT : 238.41 0.00 238.41 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 238.41 #9249
---------------
TOTAL RECEIPT : 238.41
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
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�' CITY OF ��UPERTINO
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��u���Ttfi�t�► PERMIT APPI,ICATION FORM
APN # Date:
3�1 J�-EC� oC�2 : O� � J �������
Building Address:
CQ o �.1 S�r,cQ� � � ,�c � ��-�,
Owner's Name: , Phone #:
M�-���. �c�C � � �'l - � C��-{
Contractor: License #:
�� S C�"� �,� c �7 � �-,� C)`'1
Contact: Cupertino Business License #:
�'��'�. � �L � �-� � � `�
Building Permit Info:
Bldg ❑ Elect C�" � Plumb ���� Mech '�''
.Iob Description: t� �c.�_�1 }�r�.�c: hFC� S y � �� � �-��. �c�a�y Sc�� �� �,c��d ��c � _ ti�i `I O
�-,a �.� .� ��<<<-,�� `�: , U� 3 3 �►�� �, ` �
Residential �, Commercial ❑
For Residential Installations:
� Attic � l�` floor � 2" floor ����`�
Adhere to min set back re uirement ❑
For Commercial Installations:
Replacement same weight � Additional weight (structural calcs) �
Structural Calculations required for new installation �
New installation Plannin A roval Required
Cost of Project: Type c�f Construction: Occupancy group:
� �k ��D . ��o � �2�
Strapped ❑ On Platform ❑ Bonded Cl Sc�.Ft. Floor Area:
New Locatiori � Re lacement �
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY F nergy BUILDING
BREMFURN F.elocation of Furnace MECHANICAL
BREMACOVER �`JC Unit > 10,000 cfm MECHANICAL
BREMAIRHAN �JC Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Zecptl, Switch & Outlets ELECTRICAL
BSEISMICRE ���eismic Fee Res BUILDING
EPERMITFEE �lec Pe� Issuance ELECTRICAL
— / MPERMITFEE 1�1ech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
� BPERMFEE E ldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC 3usiness License BUILDING
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