03100181CITY OF CUPERTINOh--
CONTRACT(7R INFORMATION
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PACIFIC GENERAL CONSTRUCTI
3NMIT N003100181
9770 STEVENS CREEK BLVD
R'S NAME:
38350 FREMONT BLVD
PERMIT ISSUE DAM
EVERSHINE VI, LP BLDG B
10/24/2003
ONE:
(510)713-9343
SANITARY NO CONTROL N0.
ARCHIMC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'SDECLARATION
Job Description
I thereby affirm that I am licensed under Provisions of Chapter 9 (commencing
p
with Section ]IXM)) of Oivisian l of Ne Businuu anti Profeuiom Code, end my license is
Basin.
imm�fameandeffect.
REVISION--IN HOUSE USE ONLY
License alma Lie. #
Dam Lt..
Contractor
NO NEW PERMIT ISSUED/ ORIG. #02050193
ARCHQCTS DECLARATION
1 understand my plans.hall W used as puhlic record+
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for It
"
following moron. (Section 7071.5, Business and Professions Code: Any City u, county
Which roqutms a permit to amislmel, altaF, improve, demolish, nr repair 'eny structure
prior In its issuance, also rcyuires the applicant for such Permit to File a signed statement
that he is licensed pursuant to the previsions or the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation $0
(commencing with Section 70X) of Division 7 of the Business and Professions Code) or
that he is exempt therefrom and the basis for She ajicgcd exemption. Any violation of
Occupancy Type
Section 7071.5 by ury applicant for a Permit subjects use applicant to a civil Penalty of
.or mase Nan five hundred dollars ($50)).
I, m owner of the property, or my employees with wage.as their sola comp=nasllim
'
Required Inspections
will do the work, and theawaum ianm intended or offered for sale(See. 71)44, Business
and Professions Code: The Contractor's Licerm Law does
not apply to an owner of
property who builds or improws thereon, and who does such work himself or through his
own employees, provided Not such improvements tae not intended.,offered for sale. It.
however, the building or improvement is sold within one year of complexion, the owner.
\
huilder will have the burden of proving that he did at Wild or improve fur puryosc of
woad.
Xm owner of the property, am exclusivelyand contracting with Trached contractors
��
Business and Coded The Contractor's t.
.J. the project ..ly
acme taw docs not apply m an owner of progeny who Wilda or improve thereon, and
n an rt, who Wi rad
\
e<u
whofor such projwith ac.mranort+l licensed Pursuant to the ContractorsLicensevee
\
Law. Law.
❑ 1 am a crept under Sce.9 B & P C fonhia moon
OMPENSATION
WORKERS DCC{viji ION
1 hereby affirm under Penalty of perjury one of the following declaration:
I have and will maintain v Cenificat, of Consent to self-imum for Worker's CUmpcm
$.tion, as provided for by Section 37M of the LaWr Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Wurance, as requimd by Section
7700 of the la Wr Civic, for Ne Performance of the work for which this Permit is issued.
My Worker's Compensation Imuran cauicr and Policy number am:
Cartier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the Permit is for one hundred dollars ($IU)
or Ins)
1 certify that in the perfn.O.c. of the ..,it for which this permit i+ iuucd, l shall not
employ any Person in any manner sn as Or hceome subject to the Wormn Compensation
Law. of California, Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you +heard
become Subject m the Worker's Compensation previsions id Ne Labor Code, you most
forthwith comply with such Provisions or this Permit.htll W decreed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nero is a construction lending agency for the Performance of
the work for which his permit is limited (Sec. 7097, Civ. C.)
Lender's Name
landeri Addrm+
1 certify Nm 1 haw read this application and stale Nal the all informatiun is
"
correct. 1 agree to comply with all city and county ordinances and state laws mlattng in
building construction, and hereby authorize representatives of this city to enter upon the
ahnve-mentioned property for inspection purposes.
jj
(we) agree m save, indcmni fy and keep harmless the City Of CUpenia. against
liabilities, judgments, costs and eapeme+whieb may in any way accrue.gait to City
in consequence of the Panting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE RHGUI,A 1 X
2
,
Re-roofs
Type of Roof
/ �/
Si arum of ApplicaAam
HAZARDOUS
US MATERIALS DISCLOSURE
mom or handle material
Will the applicant or future ipal Co
.
defined by the Cupertino Municipal Code, Chapter 9.I2, and the Health and Safely
k, Chapter Botha
Section 255320)?❑Yea No
hit
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
Will the applicant or rm�tam Willing Occupant tate equipment or devices which
it hmoint air contaminants as de road by the Bay Ara. Air Quality Management
all new materials for inspection.
ivict?
❑Yes KNu
Ihaw mail the haysNtionsU nalsse33and nu oftheCaldor-
nits 4.1ti thround met
7snd1s574.1 duemcup hoofing
de,amam.
north&Sntlyha
them not currently haw a unset, the. h limy zesponsibiliry m nntil'y tW rccuPenl of Ne
that It is my to OndII y
Yh
mgoimments tWmmpdortaissti... I.Cenirmaleaf Pas=r.
Sign iureofApplicant Date
d I7 U O
All roof coverings to be Class "B" or better
Owner Or
Wlagent te
fly'. j_� lr�
=ile Edit Actions Details Linos Favorites Help
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Permit Information
_ ._._ _ ._ _ _-- -- - . - -. -. _.__ _. ,_ ...
Location Information
Permit Number "
03100181 /'
Address "
19770 STEVENS CREEK BLVD
Status "
C - Closed'")
City/State/Zip CUPERTINO A 95014 I
Master Number
Notes -
II
APN irQn608f#00 C�
I Project
Unit t
Apply Date "
10J24/2003 Operator conniew
; -Owner Entity Information-
Permit Issue Date
10!24/2003 Operator conniew ,
Owner Name " EVERSHINE VI, LPJ KCR MNGMNT
Certificate Issued
` Operator {�
Use Default
Certificate Type
L
v
Address Home 19770 STEVENS CREEK BLVD ,
Certificate Number
_
City/State/Zip CLIPERTINO— 95014
_
Permit " Property Zoning
Applicant
I Contractor ' ]r
Defined Fields
—Permit Details
urpose/Special------
Permit TypeCOMML
NEWIl
REVISION --IN HOUSE USE ONLY
I
! �
DO NOT USE
NO NEW PERMIT ISSUED/ ORIG_ X02050193
i {
Usage ClassST
VJ1 HR
FILMED 5/2011 j
STORES V 1 H R
Applied Value '
CI
I
SQUARE FT.
_
— 01
.i
Calculated Value
US C-404 Type
328
[EW_ STORAGE GARAGE/SHED
Permit Form'
FAUTOPERM -PERMIT
I .Ownership
1 Private v;
_ a
i Project Size----
] j [Add Default T
'ermit issued 1012412003
anter the purpose or any special conditions for this permit
CI K —+
c
�o Back
Contractors
Fees
Plan Reviews
'FaI
Inspections
Print Permit
Adjustments
Li Holds
i
Copy Permit
10 Close Permit ff
1;
Overrides
Supplemental Fields
Notes
Attachments
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CITY OF CUPERTINO
BUILDING DIVISION PERM
C�1o1�C�O INF�iIyiA N
BUILDING ADDRESS:
PACIFIC GENERAL CONSTRUCTI
MIT N003100181
19770 STEVENS CREEK 13LVD
OWNER'S NAME:
38350 FREMONT BLVD
PERMIT ISSUE DATE
EVERSHINE VI, LP/ BLDG B
10 24/2003
PHONE:
(510)713-9343
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
REVISION --IN HOUSE USE ONLY
License Class Lica
Date Contractor
NO NEW PERMIT ISSUED/ ORIG. #02050193
ARCHITEC'T'S DECLARATION
1 understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve: demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to Ole a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation $ 0
(commencing with Section 7000) nl' Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
3 WPRMiffiborOO
Occupancy Type
P Y YP
not more than five hundred dollars ($500).
D 1, as owner of the property, or my employees with wages as their sole compensation,
will do thework, and the structure is not intended or offered for sale (Sec. 7044, Business
Required Inspections
and Professions Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve fur purpose of
salt.).
[7� 1, as owner of the property, am exclusively contracting with licensed contractors to
jcO"cl the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
censeLaw docs not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
-
0,am exem�pt uunder Sec. . B & P C for this reason
,Owne
r' / `" Y/ 17 ""mate
WORKER'S COMPENSATION DEC A ATTON
'1 hereby affirm under penalty of perjury one of the following declarations:
D I have and will maintain a Certificate of Consent to scif-insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
D 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
(This section need not he completed if the permit is for one hundred dollars ($I(X))
or less.)
1 certify that in the performance of thework for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of, the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constnrction lending agency 1'or the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
1 certify that 1 have read this application and state that the above information is
-
Correct. 1 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 in any way accrue againstsaid City
l '
U
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date .
SOURCE REGULATI NS.
Re -roofs
' y/ 7
Si azure of''Applicant/Contractor ate
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof '
Will the applicant or future building occupant store or handle hazardous material
as de0ncd by the Cupertino Municipal,Code, Chapter 9.12, and the Health and Safety
cnde„ scenezss32(a>?
,�f No
Dyes °pLl
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
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
DYes KNu
I have read the hazardous materials requirements under Chapter 695 of the Califor-
niaHealth & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
�-7
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
/ '� �/ /
requirements w tch m t be met prior to issuance of a Certificate of Nup�ney.
�'
Signature of Applicant Date
��_ i t,°/-may/o
All roof coverings to be Class "B" or better
Owner orfforizcd agent 1C
14 A�
CITY OF'
CIUPEkT1NO
�2 7-3
CITY OF CUPERTINOik�
PERMIT APPLICATION FORM C)3 tl
APN # _,
V q- &4� - 07, b4f, Id
Fee Description
Date: 'NC "(5�7
BAPPLOTHER
Other Appliances
MECHANICAL
Building Address: -72) 741
l Q %7c) 5'1-et,G15 Cr tf1C S11-1,
BUILDING
Owner's Name:
'er5kre 'LI? (-,-)o 1c, : %adq1Zee
Boiler <= 100,000 Btu
Phone #:
YaF-3 102YF d 7-3
Contractor:
Boiler > 100K to 500K Btu
License #:
BBOILER3
Boiler > 500K to 1M Btu
637 y 2,,-�
Contact:
nrs Y 7U, - 02t y��,.-l( rt%e/5�,� TO s�-
Boiler > 1M to 1.75 M Btu
Cupertino Business License#:
Building Permi Info:
Boiler > 1.75M Btu
Bldg Elect ❑ Plumb
❑ Mech ❑
Job Description:
BUILDING
Residential ❑
Commercial
Sq.Ft. Floor Area:
$/Sq.Ft.:
Cost of Project: foo
1
Occupancy Gro
Type of Construction:
Hotel and Motel
BUILDING
BCONSTAXR
Quantity Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
BBLDGFEE
Bldg Permit sq. foot
BUILDING
BBOTLER1
Boiler <= 100,000 Btu
MECHANICAL
BBOILER2
Boiler > 100K to 500K Btu
MECHANICAL
BBOILER3
Boiler > 500K to 1M Btu
MECHANICAL
BBOILER4
Boiler > 1M to 1.75 M Btu
MECHANICAL
BBOILER5
Boiler > 1.75M Btu
MECHANICAL
BCONSTAX
Construction Tax
BUILDING
BCONSTAX
Ind/Off/Comm/Quasi
BUILDING
BCONSTAXBQ
Con. Tax for BQ Zone
BUILDING
BCONSTAXH
Hotel and Motel
BUILDING
BCONSTAXR
Constax — Resi/Mobile
BUILDING
BELEC1000
Elec 600V <= 1000A
ELECTRICAL
BELEC 1001
Elec 600V > 1000A
ELECTRICAL
BELEC200
Elec Svcs 600V <= 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
BMITIGATC
Comm. Housing Mit. Fee
BUILDING
1 of