14090005 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10901 MAXINE AVE CONTRACTOR:BAY AREA BUILDERS PERMIT NO: 14090005
INC
OWNER'S NAME: KHALILNEJAD HEIDEH SEDIGHEH 318 MARTIN AVE DATE ISSUED:09/02/2014
OWNER'S PHONE: 4087686731 SANTA CLARA,CA 95050 PHONE NO:(408)648-4500
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑
PERMIT TO FINALIZE OLD PERMIT(#18725 ISSUED
License Class Lic.# 10/10/1973)TO CONFIRM(N)DETACHED GARAGE
t
Contractor � p bt C—t Wti l'
M Date '
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:$0
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:32602013 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 t—� IT 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 1 D Y L 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 Z
granting of this permit. Additionally,the applicant understands and will compl ssue by:
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date 0 6y f y 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,Sections 25505,2553//
3,an�d 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Q�Yt�/ 1 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
O�
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•building okupertino.org l
CUPERTINO
9
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/T1 ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS r ^/ �j (j�WiVg AME APN#�26 _OZ _10 1_3
OWNERNAME ` ei r`'/ �/ PHONE /`LIQ W 7-3 j E-MAIL
STREET ADDRESS ` CITY, STATE,ZIP FAX
CONTACT NAME PHONE��8�i(o E-MAIL
Gtr d/�Jfir
STREET ADDRESS O CITY,STATE, ZIP / ,� FAX
(.w LW
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME/ LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
A 6/'S• /'
STREET ADDRESS CITY,STATE,ZIP PHONE cyrU3, 07 •[O/'yL
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANYNAME �4 (I7 /Q��G� I E-MAIL FAX
STREET ADDRESS ✓ CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK �n J/ ' / 0 # (8
(%I s
/ry �• D /O l�j �-3
EXISTING USE PROPOSVD USE CONSTR.TYP #STORIES USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS ASECOND UNrr OYES SECONDSTORY []YES
BEING ADDED? ❑NO ADDITION? []NO
PRE APPLICATION F1 YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES a =" T VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO
By my signature below,I certify to each of the following: I am the property owner razed to act o erty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work andverify accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I auth presentatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: -meq o2 l�
SUPPLEMENTAL INAOR54ATION REQUIRED rr w:c> cx YrE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for OAR-THE-COUNTER ❑�RUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. , ,:J EXPRESs a Y.fEl',,PLANNING PLAN REVIEW,
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure "", sTA_P'7 n L7�)tPUBLIcwoRKs
form if any Hazardous Materials are being used as part of this project. ❑ IRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to 0`SANITARY sEwER DISTRICT"
MAJQR ,
submittal of Building Permit application.
❑tI;NVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10901 MAXINE AVE DATE: 09/02/2014 REVIEWED BY: MELISSA
APN: 326 02 013 BP#: "VALUATION: Iso
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Du lex PENTAMATION
USE: p PERMIT TYPE:
WORK PERMIT TO FINALIZE OLD PERMIT #18725 TO CONFIRM N DETACHED GARAGE
SCOPE
� ' .
A £'Ct'- Plan( 9irlC 1 hfinh Mon Wheel";
I'>t',rzr[Fi;t>. ph'imb. P< mit 1�'xee, i l,'c f'c%-
C)fhev 1 c h:SF-.
flhe))Ih hz,p. Fee Illcc, ilsp', ""c., ELLLA
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees 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 Eff 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: Hourly Only? 0 Yes Q No $0.00
Suppl. Insp.Fee:Q Reg. 0 OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Work Without Permit? ® Yes (F) No $0.00 L E)
Advanced Planning Fee: $0.00 Select a Non-Residential G
tirtFr Fees: Building or Structure
i
Stroniz Motion Fee: $0.00 1.0 hrs Inspections
Bldp-Stds Commission Fee: $0.001 $143.00 ISTINSP Inspection,Hourly
TOTAL FEE: 143.00
"YO
ALS $0.00 $143.00 $
-�
Revised: 08/20/2014
` , ' 1 r Reyoestt fpr relunds or adlust-en..n f`s mi ss be rn ade the l31n9 Offi1 in
writing:in conformance with applicti
able seconlsl Of the Santa Clara County Ordinance Code.
dAPPLICATION FOR BUILDING PERMIT t{ HEALTH DEPT.
DEPT.OF PUBLIC WORKS. SANTA CLARA COUNTY '
'
SAN DIST SAN DIST PERMIT SEP TK PERMITWATER SUPPLY
BUILDING INSPECTION DIVISION NO. NO. NO.
1555 BERGER DR. SAN JOSE,CA.95112 TEL.299-2351 SPEC DEV REQ COMP
REO. BY: DATE
37 REV 4/73 /'" ! /. �/ ,�•
JOB SITE c
r
APPROVED BY:
STREET d ADDRESS 0 e
CERTIFICATION OF COMPLIANCE DATE
E
'
NEAREST CROSS STREET
} FIRE MARSHAL DEPT.
SPEC(COMMERCIAL) DEV REO COMP
I POST OFFICE(CITY) fn ejZIP 54n REG BY: DATE
t Qf-s
OWNER cha,4 r Q PHONE
MAILING
ADDRESS �, AUe
ZIP SCJ ar
APPROVED BY;
i'
CITY y.i•'n r� • CERTIFICATION OF COMPLIANCE PATE
•
ARCHITECT PHONE lam• PLANNING DEPT.7� �d
ENGINEER tFEET
FRONT IFROM CENTER SIDE REAR ZONE )))
CONTRACTOR BLDG ELEC PLG M£CH SEL OTHER UNE OF R/WI
.- Ge,M0.V% LIC.NO. CLASS VARIANCE OR DEV REO COMP
PHONE 73-3 9 7� SPEC REO. '�""" BY: DATE 1
MAILING 1 4Q O 11 4ye j n�P7tsC r G ARCH.SITE
ADDRESS C4 Cs^�1'1 ZIP JS pI tf APPROVAL BY:
CERTIFICATION OF COMPLIANCE IS REQUISITE TO ISSUANCE OF CERTIFICATE OF '
OCCUPANCY,CERTIFICATION SIGNIFIES COMPLIANCE-WITH ALL APPLICABLE SANTA Q 1�
CLARA COUNTY ORD.CODES UNDER DEPARTMENTAL PURVIEW.
BUILDING INSPECTION DIV,
LOT S TRACT $U I PLAN CHECK NO. APPROVED BY: IQ-IO"7�
BLOCK5 A.P.N. .2 L/ CERTIFICATION OF COMPLIANCE p47E
TYPE OF IMPROVEMENT THISSPACE FOR INSPECTOR'S USE ONLY
BUILD REMODEL ADD TO REPAIR MOVE CONVERT DEMOLISH
' SO,FT. 1 D No.Ot No,of
SIZE W FAMILIE5 •"`� STORIES ��•
SPEC OE V.REO.COMP,
REG BY: DATE.
PE IT UIMERusE of INSPECTION RECORD
STRUCTURE DATE L INSPECTOR REMARKS
1. FOUNDATION FORMS
2, FORMS
POUR NO CONCRETE UNTIL THE ABOVE HAS BEEN SIGNED
3. HEATING-DUCTS
APPROVED BY:
4. COMFORT COOLING
CERTIFICATION OF COMPLIANCE DATE 5. GIRDERS
ENGINEERING SERVICES DIV. DO NOT COVER FLOORS VN fIL THE ABOVE HAS BEENSIGNED
LAND OAT EV��47 '73j / //�+ ^ ///��� 6. BOND BEAMS(CONC.BLK.)
DEV
�e / �� ROUGH►TBG.
FILE NO.
1 REQ. PARCEL NO. 7. PARTIAL
COMP, BY ROUGH PLBG.
7A COMPLETE
1
❑
EIR REQUIRED Q'"- '-- '4"[�Yes De1eNn B' SEWER INSPECT
9. GAS PRESSURE
ROUGH INCLUDING ROOF. ' G
DWY APPROACH INSP BY DATE 10, FRAME-FLUES AND SIDING
CONST. DO NOT WIRE UNTIL THE ABOVE HAS BEEN SIGNED
INSP, ROAD IMP❑ INSP BY DATE
I
COMPLETE/;F.VV.CCUPANCY❑ BOND❑ DATE 11. ROUGH ELECTRIC WIRING
APPROVED BY- COVER NO WALLS UNTIL THE ABOVE HAS BEEN SIGNED
CERTIFICATION OF COMPLIANCE DAA 12. STUCCO WIRE OR LATH e•'j'
12A•SHEET ROCK
BUILDING SEPTK F,M,FEE For Reference Only
VALUATIFEE FEE ELEC. 13. PLUMBING FINAL(Fistures)
ON
PLANd
� Q Survey/1 hr, 14. GAS APPLIANCES sd O StO min•
CHECK dZ PLg, 15. ELECTRICAL FINAL(Fixtures)
Iswence IS. BUILDING COMPLETE
PERMIT tj�0 P>rmjt —,o F3
7 ,\iJME CN. NO UTILITIES WILL BE CLEARED UNTIL"BUILDING COMPLETE"HAS BEEN SIGNED
THIS SPACE FOR MACHINE VALIDATION ONLY
NOTE: TOTAL FEES U
EXCLUDES APPLICABLE TOTAL FEES J r
ELECTRICAL,PLUMBING ^
AND MECHANICAL PERMI T //'�� JU n
FEES. l 57 p ZJ
J OPAALL FEES � q PERMIT NO" r•1
PERMIT NUMBER ISSUEb BY DATE 1 ,,, .,i p �,� r{1r)
THIS APPLICATION IS A VALID PERMIT WHEN PROPERLY FILLED OUT,SIGNED,AND MACHINE VALIDATED IN THE
SPACE PROVIDED. PERMISSION IS THEREFORE GRANTED TO DO THE WORK INDICATED IN ACCORDANCE WITH ALL
APPLICABLE ORDINANCES, LAWS AND REGULATIONS.
PERMIT IS SUBJECT TO ALL APPLICABLE SECTIONS OF SANTA CLARA COUNTY ORDINANCE CODE..'1.4.
THIS PERMIT SHALL EXPIRE BY LIMITATION AND BECOME NULL AND VOID IF'WORK IS NOT COMMENCED WITHIN
60 DAYS.
"REFUND:WHERE NO PORTION OF THE WORK OR CONSTRUCTION COVERED BY THIS PERMIT HAS BEEN COMMENCED
BEFORE THE EXPIRATION DATE HEREOF, REQUESTS FOR REFUNDS MUST BE MADE IN WRITING TO THE DIRECTOR OF
THE BUILDING INSPECTION DIVISION ON OR BEFORE SEVENTY-FIVE (75) DAYS FROM THE DATE OF ISSUANCE OF
THIS PERMIT"
GRADE LINES AS SHOWN ON DRAWING ACCOMPANYING THIS APPLICATION ARE ASSUMED TO BE CORRECT. IF
ACTUAL GRADE LINES ARE NOT THE SAME AS SHOWN, REVISED DRAWINGS SHOWING CORRECT GRADE LINES, CUTS
AND FILLS, TOGETHER WITH COMPLETE DETAILS OF RETAINING WALLS AND WALL FOOTINGS REQUIRED, MUST BE
RESUBMITTED TO THIS DIVISION FOR APPROVAL.
INSPECTOR MUST BE GIVEN 24 HOURS NOTICE FOR EACH INSPECTION.
IN CONFORMITY WITH THE PROVISIONS OF SECTION 7031.5 OF THE BUSINESS AND PROFESSIONS CODE AND SECTION
3600 OF THE LABOR CODE OF THE STATE OF CALIFORNIA, APPLICANT SHALL FILE WITH THE BUILDING INSPECTOR
THE CERTIFICATES DESIGNATED IN (1) AND (2) BELOW AND/OR SHALL INDICATE ITEM (3), (4), (5) OR (6) WHICH-
EVER IS APPLICABLE.
(1) CERTIFICATE OF CONSENT OF SELF-INSURED ISSUED BY THE DIRECTOR OF INDUSTRIAL RELATIONS.
(2) CERTIFICATE (OR EXACT DUPLICATE COPY) OF WORKMEN'S COMPENSATION INSURANCE ISSUED BY AN
ADMITTED INSURER.
c I . (3) THE COST OF THE WORK TO BE PERFORMED IS $100 OR LESS.
(-*(*4*1 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 WORKMEN'S COMPENSATION
LAWS OF CALIFORNIA.
(5) 1 CERTIFY THAT THE APPLICANT IS LICENSED UNDER THE PROVISIONS OF CHAPTER 9 (COMMENCING AT
SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE AND SAID APPLICANT'S CALIFORNIA
STATE CONTRACTOR'S LICENSE NO. CLASS IS IN FULL FORCE AND EFFECT.
(6) APPLICANT IS EXEMPT FROM(5)ABOVE UNDER THE APPLICABLE PROVISIONS OF SECTION 7040 THROUGH
SECTION 7053 OF THE CONTRACTOR'S LICENSE LAW. (STATE BASIS FOR EXEMPTION.)
}/ APPLICANT'S
SIGNATURE 4''`� PHONE
APPLICANT'S
ADDRESS ZIP CODE
AGENT'S
SIGNATURE
DECLARATION OF CONSTRUCTION LENDER
PURSUANT TO SECTION 1193 OF THE CODE OF CIVIL PROCEDURES, AN APPLICANT IS REQUIRED TO
INDICATE THE FOLLOWING.
1) NAME OF CONSTRUCTION LENDER BRANCH DESIGNATION
ADDRESS ZIP CODE
2) THERE IS NO CONSTRUCTION LENDER. f� J
APPLICANT'S SIGNATURE DATE