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14090059 CITY OF CUPERTINO BUILDING PERMIT BUILDING.ADDRESS: 10380 STERLING BLVD CONTRACTOR:JALILI MOHSEN H ET AL PERMIT NO: 14090059 OWNER'S NAME: JALILI MOHSEN H ET AL 10355 STERN AVE DATE ISSUED:09/11/2014 OWNER'S PHONE: CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL DEMOLISH EXISTING RESIDENCE(1127 SQ FT)AND License Class Lic.# GARAGE(264 SQ FT). Contractor 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. 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 Workers 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:$8000 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:37524008.00 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 save 180 DAYS FROM 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 granting of this permit. Additionally,the applicant understands and will comply Issued Date: 9 ' with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date All roofs shall be inspected prior to any rooting 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: Dale: 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 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) 1,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(x)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 Cuper 'no Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 50_ 2153 ,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: 01-1\— permit is issued. � y I certify that in the performance of the work for which this permit is issued,1 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shalf be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source re ul io s er the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date G"rt�y1 l CITY OF CUPERTINO C1FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10380 Steling Blvd DATE: 09/11/2014 REVIEWED BY: Sean APN: BP#: , VALUATION: $8,000 PERMIT TYPE: Demolition Permit PRIMARY SFD or Duplex PENTAMATION 1 SFDWL-DE USE: PERMIT TYPE: i WORK Demolish existing residence 1127 sq ftand Garage 264 sq ft). SCOPE FEE ID FLR AREA s.f. 1DEMORES 1,391 Ll NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn't info. FEE ITEMS (1,ce Resolution 11-053 Eff 7`1."13) FEE QTY/FEE MISC ITEMS Permit Fee: $574.00 Suppl. Insp. Fee:Q Reg. © OT 0.0 hrs $0.00 i Stron Motion Fee: IBSEISMICR $1.04 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $576.04 $0.00 TOTAL FEE: $576.04 Revised: 08/20/2014