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14060014 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21481 ELM CT CONTRACTOR: A—/ PERMIT NO: 14060014 �o�Shu L-fi rI OWNER'S NAME: MAHROUYAN REZA AND AZAR DATE ISSUED:06/03/2014 OWNER'S PHONE: 4085157428 PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL ❑ REPAIR WATER DAMAGE IN(E)SHOWER IN MASTER License Class�j � _ Lic.# Z BATHROOM Contractor � 1I l�l eQ- ejR�Date 6A.12nLl I hereby affirmmthat I am licensed under the provisi s 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:$3500 I ave nd 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:36201021 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 180 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 saveessued LLED 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 granting of this permit. Additionally,the applicant understands and will com Date: with all non-point source regulations per he Cupertino Municipal Code,Section 918. RE-ROOFS: Signatur Date �� 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 b the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance wit the pertino 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 s 25505,2�5j533, n 534. / Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: 4 Date: 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 CONSTRUCTION PERMIT APPLICATION �O COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O LEE (408)777-3228• FAX(408)777-3333•building (aDcupertino.org \a CUPERTINFO ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS f1 1 � ct APN# �I 0 OWNERNAME Re�A6 Mah)-0u _a PHONE (405 �� _ �� E-MAIL y� a� rDu a-A � ah 00_ COW STREET ADDRESS ^ GT /e CITY, STATE,ZIP C(J,` n� ^n O Ct( q�pL FAX CONTACT NAME R e&IJP 1 V`�'Y,rolU &IA PHONE(409) I4q L V E-MAILrw aP rO0 STREET ADDRESS CITY,STATE,ZIP /r FAX �/ C ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT Fg ACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# �, A` unE 2 `.' NY NAME E-MAIL FAX .�/Ob A::1 C4nAkmot-70A gzm 64(g) a m X44-Cl ;ZJ7 STtEET ADDRESS CITY,STATE,ZIP r4 aq__>z 12 r Wo ARCHITECT/ENGrNEER NAME LICENSE NUMB6 BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK 2 �J EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION($) es EXISTG NEW FLO R DEMO TOTAL AREA AREA AREA NET AREA BATHROOM ' KITCHEN OTHER REMODEL AREA V REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH []ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑ICES ",BY _ �` i,,L, OTAL VALUATION: PLANNING APPL# E]NO PLANNING APPROVAL LETTER EICHLER HOME? E]N AA By my signature below,I certify to each of the following: I am the property owner ora orized agen TN on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating t building construction. I alt rize representatives of Cupertino to enter the above entified property for inspection purposes. Signature of Applicant/Agent: % Date: SUPPLEMENTAL INFO ATIONREQUIRED f,_ ,PLakcHEcic;T�rE RovTiNcsaP r x � _New SFD or Multifamily dwellings: Apply for demolition permit for CIovEit THlrcourrTER ❑ soil D>rcriAl�xEVIEw existing building(s). Demolition permit is required prior to issuance of building �'k permit for new building. EXPRE35�= r ❑ PLANNINGPLA'!�REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure C� sT�IvnARD j ❑ PVBLIc woRxs form if an Hazardous Materi�are being used as part of this project. " f Y 4, I ARGE li � FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to � o� �4 a ❑ SANITARSEVYER�ISTRICT submittal of Building Permit application. e,.,`t �'a.';�' ,ENV�IROIVMENTr1L'HEALTH c BldgApp_201 Ldoe revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21481 elm ct DATE: 06/03/2014 REVIEWED BY: MELISSA APN: 362 01 021 BP#: *VALUATION: 1$3,500 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPFIX USE: p PERMIT TYPE: A WORK REPAIR WATER DAMAGE IN E SHOWER IN MASTER BATHROOM SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Fixture set on One Trap 1BPFIXTURE 1 # $10 TOTALS: $10.00 . ,i kch. 11lcrrt Check Plumb.Plan Check 0.0 hrs $0.00 1,lec-. i'/an Check L2e>ct:. Permit Fee.— Plumb.Permit Fee: IPPERMIT !s.'ec- 1'erttzit OdW,-Alech. 7rt,>'v Other Plumb Imp. 0.0 Ins $47.00 oflaer,1,/ec. Crar>. Ltech.Ixsz)_Fee,: flhwib. Irrsp. Fee: l tec.Irs'o NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept-for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef. 711/13) FEE QTY/FEE MISC ITEMS t'h, r t'hec.t- suppl. 11(`1 fee° F71 A PME Plan Check: $0.00 Permit PME Unit Fee: $10.00 PME Permit Fee: $47.00 i.on, tradclion 1`6U., Administrative Fee: ]ADMIN $44.00 Work Without Permit? 0 Yes (F) No $0.00 ,10111*0=11c d PlartY ing 1`'e es Travel Documentation Fee: ITRAVDOC $47.00 A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.001 1 $149.50 $0.00 i = TOAL F.EE., $149.50 Revised: 04/01/2014 2 .14-0 i � Ct C � � � < <ro CA 95014- -5 ,:f 5014- I IN COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION-CUPERTINO APPROVED Y-0, e- This set of plans and specifications MUST be kept at the Job site during construction. It is unlawful to make any c-V� changes or alterations on same,or to deviate therefrom,without approval from the Building Official. The stamping of this plan and specifications SHALL NOT Ru C% Po be held to permit or to be an ioiation �R�`//Vo J b°� of any pro ' y C. c ate Law. REVj -� J,"i' 0 3 �t I INS �a'6 I Y � q/ DATE 3 Revl6wed ley, OC? COMP t V i'I^ Y l7U'mPERMIT NO. �l �/A c h C4 ('l a.o eed 3``1 b W ' C � - RECEIVED --- 'UN 0 2 2014 BY