13110007 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10050 HILLCREST RD CONTRACTOR:-TBft—feH30E PERMIT NO: 13110007
OWNER'S NAME: MOHAMMAD MORADI lltl/`��-S'�Lf DATE ISSUED: 11/01/2013
OWNER'S PHONE: 5104681104 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License ClassLi,# � INSTALL GAS LINE FOR FUTURE BBQ ISLAND
� � _
Contractor Date 1
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:$500
�al 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:32616096.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 1 0 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the �/•/.�/�
Issued by:
granting of this permit. Additionally,the applicant understands and will comply Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. �I --
f, zv RE-ROOFS:
Signature Date L 3 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
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se ti ns 550 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: ��/�l Izeg
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
--
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 ARCHITECT'S DECLARATION
Indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION b�/r
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 d
CUPERTINO (408)777-3228• FAX(408)777-3333•buildingCoDcupertino.org 6�1 MISC
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❑OWNER OWNER-BUILDER OWNER AGENT 11 CONTRACTOR CONTRACTOR AGENT ARCHITECT ENGINEER 11
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USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YESPROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: El COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION: RECE
By my signature below,I certify to each of the following: I am the property owne,t orauthorized agent to aefo t property owner's behalf. I have read this
application and the information I h ve provi d I correct. I have read the Description of Work and verify it is I curate. I agree to comply with all applicable local
ordinances and state laws relating Eo builing conttruGbn. I authopze-fepresentatives of Cupertino to enter the above-iden ifiied property for inspection purposes.
Signature ofApplicant/- lV J Date:
SUPPLEMENTAL INFORMATION REQUIRED oF � Ts eSi�"
OVER THE CUUNTER
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10050 hillcrest ct DATE: 11/01/2013 REVIEWED BY: MENDEZ
APN: BP#: "VALUATION: $500
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1RPGAS
USE: PERMIT TYPE:
WORK install gas line for future bbq island
SCOPE
bYcr,�Ch"( Plumb.Plan Check 0.0 hrs $0.00 �'`�'��. t�t'(`h,%k
Plumb.Permit Fee: IPPERMIT t;l<<
It(,,h, Ire , Other Plumb Insp. 0.0 hrs $47.00 0""Ict,17e�
E3
1leci, h �t�.Ie; 1'.%irirrh_ fir7z Ii, : liec.Inif. 1°�'i°:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prelinddna information available and are only an estimate. Contact the Dept for addn'I info.
FEE ITEMS (Fee Resolution 11-053 E .� 7i1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F 1-1 # Plumbing
Suppl.PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $70.00 1BPGAS Piping,Gas>4 Outlets
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:Q Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
('011.WruCiinr7 l Jv.
Administrative Fee: IADMIN $44.00 0
Work Without Permit? 0 Yes (F) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Building or Structure
Travel Documentation Fee: ITRA VDOC $47.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg_Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $139.50 $70.00 TOTAL FEE: $209.50
Revised: 10/01/2013