151100394
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CITY OF CUPERTINO BUILDING PERMIT
BUILDING -AD 65 S,TANTAU AVE
CONTRACTOR: ALI GHOREISHI
PERMIT NO: 15110039
OWNER'S NAME::, ALI GHOREISHI
965 S TANTAU AVE
DATE ISSUED: 11/06/2015
OWNER'S PHONE:.' 4083099297
CUPERTINO, CA 95014
PHONE NO:
❑ .;. a' is LICENSED'CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
CiJ PRopC�7� LiNc-
License Class Lic.'#'
Date
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our
Er rTA
Contractor
I hereby affirm ,that,I ain licensed under the provisions of Chapter 9
'
(commenSing,�vith'•Sectio:*n.0) 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,piovrded 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: $2800
.R
I 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: 37538053.00
Occupancy Type:
permit is issued;= „j i
!' 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 save
180 LAST CALLED INSPECTION.
indemnify;'�and.keep'harmless the City of Cupertino against liabilities, judgments,
'expenses which City in consequence of the
r
costs; and may. accrue against said
granting of this permit-: Additionally, the applicant understands and will c y
Y
with all non -point source regulations per the Cupertino Municipal C , S
9.18. ;.
KRLE-ROOFS:
Signature !. -�:, •' ' •, Date
All roofs shall be inspe oofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
l 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 theiproperty; 6r1iny employees with wages as their sole compensation,
will do the work; and'the structure is'riot intended or offered for sale (Sec.7044,
Business & Professions Code) .
, as owner of the property,; am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7„0.44, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
• r +:: i) .
I hereby affirm under penalty of perjury one of the following three
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations: ';+. I ;`,' :
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 andwill mairitain`Worker'.s Compensation insurance, as provided for by
the.,Health & Safety Code, Section 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the. performance of the work for which this
Owner or authorized agent:14 Date::
ermit is issued.+; • , :' . ,,
certify that in the performance of the work for which this permit is issued, I shall
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not einploy:any'person in -spy manner so as to become subject to the Worker's
Compensaiion;laws of.Califoiilia. 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.sucb provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
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
to building constriction 'and hereby authorize representatives of this city to enter
upon,the above mentioned property for inspection purposes. (We) agree to save
indemni 'ano,kee harmless the Ci of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
sich may accrue against said City in consequence of the
costs;'andexpense'wh
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
E1.
9.18.:��
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Signature+ Da
GENERAL PERMIT APPLICATIONMEP
�g COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 - buildinO(8)cuoertino.ora
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USE OF ❑ SFD or DU -PT ^Y MULTI -FAMILY PROJECT LN WILDLAI\TD ❑ YFS PROT= LN ❑ YES
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By my signature below, I certify to each of the following: I Pm -the property Q<vner or authorized went to act on the pr ope s ehalf. I have read this
application and the information I have provided is correct. I have read the Description of Work aad verify it is a 'gree to comply with all applicable local
crdances pad smote lz%� s relati g to buiidin cons ction. I authorize representatives of Cupertino fo ehe: tae above -identified property for inspection purposes.
Si=ure ofApplican /Agent: Date:
SU-PPLEI\ ENTAL L\tF'OR✓fATION REQULp,.ED
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hlEP &SC,4Dp_?011.doc remised 0621/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 966 S TANTAU AVE DATE: 11/06/2015 REVIEWED BY: MELISSA
APN: 375 38 053 BP#: *VALUATION: 1$2,800
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1 RPSS
WORK INSTALL (N) PROPERTY LINE CLEAN OUT
SCOPE
Alech—1 lan (7he.,�k
Plumb. Plan Check 0.0 1 hrs $0.00
Elec% Plan Check
ije 'i..Pornai4T'ee:
Plumb. Permit Fee: IPPERMIT
`lec, Perlpf it Fee:
*r -fech. hlsp
Other Plumb Insp. 0.0 hrs $48.00
Imp.
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ech, h -vv. he4,.
Plwnh 1,
-ist
-,70c. Ir
1, �sp. I 2?:
NOTE., This estimate. does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
,u1strict,efc.). Ifiesefees are Dasea on the preliminary information available and are only an estimate. Contact the Dept for addnl into.
FEE' ITEMS (Fee Resolution 11-053 Eff, 711113,
FEE
QTY/FEE
MISC ITEMS
11 -in (:7ieck 1-7ee.,
Sulj.)L PC.Fee
PME Plan Check:'
$0.00
Perinit Itee:
PME'Unit.Fee:
$25.00
PM,[E:Permit F,ee:
$48.00
Administrative Fee: 1ADMIN
$45.00
Work Without Pen',nit? 0 Yes (E) No
$0.00
Travel Documentation Fee: ITRAVDOC
$48.00
Strom Ni6iibn Fee:',,',,,, IBSEISMICR
$0.50
Select an Administrative Item
Bld '�S;fdS'C'0�'�miniss'ion Fee: 1BCBSC
$1.00
... ... ... .. . A'
SUBTOTALS "
$167.50
$0.00
OTA
167.501
Revised: 10/01/2015
rAAOWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • buildina(Icupertino.ora —
CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS 96g^ S ` "fw��IJ /�=�7�: _ .....APN...
BP�
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OWNER N VqE aY`E t t'._ ... ....._..:.
AA
OWNER ADDRESS: -Tcw4,`J
DESCRIPTION OF WORK:
We are providing you with an Owner -Builder Ackhowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Blger" building permit that erroneously implies that the property owner is providing his or her own labor and material
psponally. I, as an. Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
ar'_'uhlicensed person and his or her employees while working on my property. My homeowners insurance may not
of my
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits
insuance coverage for injuries to workers on my property.
2. I understand. building permits are not required to be signed by property owners unless they are responsible for
theeonstruction and are not hiring a licensed Contractor to assume this responsibility.
I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
Tfee
prot myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
namefinstead of my own.
4'. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
nu ;b'ers on permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tot9,I'walue of my construction is at least five hundred dollars ($500), including labor and materials, I may be
con t ered an "employer" under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
fed'e''��'I government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
'
unem" ploym..nt compensation for each "employee." I also understand my failure to abide by these laws may subject
meff l,serious financial risk.
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7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
resd;✓ntial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licrised subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is p;e'rformed under contract with a licensed general building Contractor.
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8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
A,y financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
d`eects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 0.4/14/10
I understand I may obtain more information regarding my obligations as an "employer" from the Internal
e Service, the United States Small Business Administration, the California Department of Benefit Payments,
California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
Board (CSLB) at 1-800-321-CSLB (2782) or vmv.cslb.ca.gov for more information about licensed
rs.
0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
party legally and financially responsible for proposed construction activity at the site address listed above.
I agree that, as the party legally and financially responsible for this proposed construction activity, I will atrfde
plicable laws and requirements that govern Owner -Builders as well as employers.
2. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
infor r ation-I have -provided on this form. Licensed contractors are regulated by-laws designed to protect.the-public. If
you contract with -someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a. result of a complaint...Your only remedy against unlicensed
Contractors maybe in civil court. If is also important for you -to understand that if an unlicensed Contractor or
employee of that individual or firm is injured .while working on your property, you maybe held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not--
those
otethose Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following constructioh lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification alceptable to the city may be required to be presented when the permit is issued
J. vedfv the property owner's sionatur . 7
Property Owner's Signatu
--------------------------------------------------------------------------------------------------------------------------------------- ------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
CwnerBuilderForm 2010.doc revised 04114110
CUPERTINO
Address
PURPOSE
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building() cupertino.org
N 4 # of
FILE
11-1 7-y — M &
Permit No. 1 ti) 1 o o 3 9
PERMIT CANNOT BE FINALED AND CONIPI,ETED UNTIL THIS CERTIFICATE
[IAS BEEN SIGNLQ AND RFTIENED TO THE BUILDING DIVISION
This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA
SMOKE ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sleeping room
X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
I have read and agree to comply with the terms and conditions of this statement
Ow w (or Owner Agears) Name.
Ar L, h eff 1
Signature ......... `.................................................................. Date:
Contractor Name:
Sinature................................................................... Lica...................................... Date: ...................
Smoke and CO form. doc remised 03/18/14
CUPERTINO
Owner Name
WATER -CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
FILE
0- 7--1 ri
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org
4 Permit No
Address
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
No Go to Question 2.
2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its
plumbing, installation of water -conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the forn and sign bottom of form.
P( No Go to Question 3.
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
LKNo Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
14 Yes My real property is built and available for use or occupancy on or before January 1, 1994.
Civil Code Sections 110 1. 1 through 1101.8 apply. Check one of the three following statements and sign
bottom of form..
5. Please check ONE of the following:
;K My property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non-
compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water -
conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or
improvements).
❑ My property is a commercial real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non- compliant
plumbing fixtures to be replaced with water -conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements).
I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be
replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 1 101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's
installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the
table on the following nave.
Owner or Owner Agent's Signature: a 2 Date:
Upon completing and signing this Certifi ate, please return it to the Building Division in order to final vrnir hirildinv npr ;r
SB407 2015.doc revised 08/26/15