13050016CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18920 TILSON AVE
CONTRACTOR: MOHSEN JALILI
PERMIT NO: 13050016
OWNER'S NAME:
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALS
❑, LICENSED CONTRACTOR'S DECLARATION
DEMO (E)1000 SQ FT SFD
License Class Lia #
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.
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
Valuation: $9000
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3760 of the Labor Code, for the performance of the work for which this
APN Number: 37509017 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMI EXP S IF WORK IS NOT STARTED
correct. I agree comply with all city and county ordinances and state laws relating
WIT 18 AYS OF PERMIT ISSUANCE OR
to building constrtr uction, and hereby authorize representatives of this city to enter
180 D S OM LAST CALLED INSP CT ON.
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
Issued b Date:
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:
RE -ROOFS:
Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
Signature
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
ALL ROOF. COVERINGS TO BE CLASS "A" OR BETTER
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
do' the work, and the structure is not intended or offered for sale (Sec.7044,
will
Business & Professions Code)
1, asowner of the am exclusively contracting with licensed contractors to
proe
p
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Seci 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:
I have and will maintain'a Certificate of Consent to self -insure for Worker's
Health & Safety Code, Section 25532(a) should I store or handle hazardous
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
with the Cup rtino Municipal Code, Chapter 9.12 and.
performance of the work for which this permit is issued.
and maintain Compensation Insurance, as provided for by
will maintain compliance
the Health & Safety Code, Section
Compensationlaws of California. If, after making this certificate of exemption, I
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor Code, I must
work's for which this permit is issued (Sec. 3097, Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked.
p y p p
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,
expenses 'which. may accrue against said City in consequence of the
I understand my plans shall be used as public records.
costs, and
granting of this permit. A itionally, the applicant understands and will comply
with all non -point source gulations per Code, Section
Licensed Professional
9.18.
Signature Date���
r
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 18920 TILSON AVE
DATE: 05/02/2013
REVIEWED BY: MELISSA
APN: 375 09 017
BP#: G' 01
*VALUATION:
1$9,000
f;t
*PERMIT TYPE: Demolition Permit
PLAN CHECI: T)PE:
PRIMARY
SFD or Duplex
PENTAMATION
1SFDWL-DEM
USE:
PERMIT TYPE: 'A
WORK
DEMO E 1000 SQ FT SFD
SCOPE
FEE ID FLR AREA
s.f.
1 DEMORES 1,000
Xfech, Plan Check
PlimA Plan Check
Elec. Plani Check
Nfech, Pe7 nnh Fee:
Phimb. Permit Fee:
Glee, Permit Fee:
Other Afech. Insp.
Other Plumb 7rtsp.ET-1-
Other Elec. Insp.
jtlech, Insp, Fee:
Plumb. lay. Fee:
Glee. Insp, Fee. -
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 nreliminary information available and are onlv an estimate. Contact the Dept_ for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/U12)
FEE
QTY/FEE
MISC ITEMS
P/(174 Check Fee:
Suppl. PC Fee:
Phnnb./1llech,/Elec
Permit Fee:
$534.00
Suppl. Insp. Fee:Q Reg. Q OT
T 0 0
hrs
$0.00
Plur77b./17lech. Elec
PhuwbJR4'eeh,1Plec Perinit Fee:
C071S11-17CtiOn T OX.-
Ad7nhiistralive Fee:
�,Vork. WithoutPerniiO
Advanced Planning Fees:
A
Trm>el Docinnentotion Fees:
Strong Motion Fee: IBSEISMICR
$0.90
Select an Administrative Item
131dg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$535.90
$0.00 TOTAL FEE:
$535.90
Revised: 04/29/2013