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14110110CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 22765 SAN JUAN RD OWNER'S NAME: HASHEMI SIAMAK AND NEHAWANDIAN NASI OWNER'S PHONE: 8182926435 j LICENSED CONTRACTOR'S DECLARATION License Class y r � Lic. # & &a G M /3 Contractor _ r- nis (�1s�l� J4(1-/ i�Date 1 tp/ 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: 1 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 Qerformance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the j �}�r Code, for the performance of the work for which this permit is issued. 7� ✓/ or 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 construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 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 comply - with all non -point source regulations per the Cupertino Municipal Code, Section Signature- ! %��G� pa1�lJ�G�7 ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 1 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 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 comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature, Date CONTRACT( PERMIT NO: 14110110 (J/u rn DATE ISSUED: 01 /16/2015 PHONE NO: JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL 0 INSTALLATION OF INGROUND GUNITE SWIMMING POOL (405 SQ FT) AND SPA (113 SQ FT). Sq. Ft Floor Area: 1 Valuation: $50000 9 APN Number: 34222031.00 1 Occupa ney Type: I PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FRO LED INSPECTION. d ate: RE- ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code „Section 25532(a) should I store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Munici al Code, Chapter 9.12 and the Health & Safety Code, Secti 5505, 25533, 5534. Owner or authorized agen �°�� Date if� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Profess /'/-// o //o C®NSTRUCTI®N PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT ^ BUILDING DIVISION 10300 TORRE AVENUE e CUPERTINO, CA 95014 -3255 La CUPERTlMO (408) 777 -3228 • FAX (408) 777 -3333 o buildinp(gkupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS p I APN # �� r � OWNER NAM j� Iv PHONE�� E -MAIL C/ STREET ADDRESS--% / �A CITY, STATE, ZIP FAX Dai CONTACT NAME - &< PHONE I�^7��i, d -MAIL (- STREET ADDRESS � � y 4 -,5r lr�q r_ C �C�7 AG7 95-3 45 t FAX (� ❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT PNTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME qM,^ ^ - � A`^� u .LICENSEZJLj�B / � LICENS &TY BUS. LIC# COMPANY NA( n/ G _V, E M LC `4 C-" 0 rv� Y14110D • /i ei„ STREET ADDRESS L CITY, STATE P EXISTING USE ARCHITECTIENGINEERNAME LICENSE NUMBER USE BUS. LIC# COMPANY NAME SQ.FT. E -MAIL EXISTG AREA FAX STREET ADDRESS DEMO AREA CITY, STATE, ZIP TOTAL NET AREA - PHONE DESCRIPTION OF WORK # UWtLL1NG UNI Is: 15AJLt- U11111�11 UYCJ BEING ADDED? E] NO JGLVIVU JIUKT UYLJ ADDITION? C] NO EXISTING USE PROPOSED USE CONSTR TYPE I # STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG AREA 4 �y NEW FLOOR AREA DEMO AREA TOTAL NET AREA - By my signature below, I certify to each of the following: I am the property owner or authorized agent to act 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 BATHROOM REMODEL AREA ut rize representatives of Cupertino to enter the above- ii'deent %ified pro� /etty to inspection purposes. Date: KITCHEN REMODEL AREA OTHER, REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIFORCH AREA GARAGE AREA: DETACH I] ATTACH # UWtLL1NG UNI Is: 15AJLt- U11111�11 UYCJ BEING ADDED? E] NO JGLVIVU JIUKT UYLJ ADDITION? C] NO PRE - APPLICATION ❑YES IF YES, PROVIDE COPY OF PLANNINGAPPL# EINO PLANNING APPROVALLETTER IS THE BLDG AN ❑YES EICHLER HOME? ❑NO c RECEIVED Y �_ ' I ' = )x '� "+_ TOTA VALUATION: ` 4 �y �� By my signature below, I certify to each of the following: I am the property owner or authorized agent to act 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 to ilding constructio n. Signature of Applicant/Agent: OA -4.101 ut rize representatives of Cupertino to enter the above- ii'deent %ified pro� /etty to inspection purposes. Date: SUPPLEMENTAL INFORMATION REQUIRED - New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. Commercial Bldgs: Provide a completed Hazardous Materials Disclosure fo- rm if any Hazardous Materials are being used as part of this project. _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. B1dgApp_201 Ldoc revised 06121111 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 preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 UL 711/13) ADDRESS: 22765 San Juan Road DATE: 11/19/2014 REVIEWED BY: Sean *'f APN: SP #: *VALUATION: 1$50,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD Or Duplex USE: $0.00 PENTAMATION RBS d PERMIT TYPE: WORK Installation of in round swimming pool and spa 400 sq ft). SCOPE O,Q 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 preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 UL 711/13) Afccch. Plan Cherk E Phwih.PlunChccd QTY/FEE :blecfr. permit Fee. Numb. Permu ! ec: 1;1ec Pclwir Vev Usher 1h,ch, lrts;n nlher PIVrnh Ins1, 90 .`l, r 1, 7sn. 110o !7. snap,. /,,?c f 1umh. 1nst,. Fee: e l I. ; . 1 :•. ' 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 preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 UL 711/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 400 s.f. Swimming Pool $1,574.00 1POOLGUNIT Gunite Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. COT O,Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consiruction Tax: El ,ldrninistrativo, fiL' e: E) Work Without Permit? Yes (D No $0.00 Advanced Planning Fee. $0.00 Select a Non - Residential E) Building or Structure A 7ra,�el lanl��l.�emenlalion Fees Strong Motion Fee: IBSEISMICR $6.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $8.50 $1,574.00 TOTAL FEI $1,582.50 Revised: 10/01/2014