08100068 CITY OF CUPERTINO Tam F.ra�afc+ ,d�`"€''-' �
1115ILDING DIVISION PERMIT K,.0NTRA.CTORINIr„UI.tMAT,ION
BUIL 1 G O ESS: PERMfr NO.
STEVENS CREEK BLVD APT ORION FINANCIAL SERVICES 08100068
OWN AME: PERMIT ISSUE DATE
PROMETHEUS REAL ESTATE GROUP PO BOX 693 10/13/2008
NE.
(916) 789-8484 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
'
BLDG ELECT PLUMB MECH
0 0 0 0
u00, LICENSED CONTRACTOR'S DECLARATION lob Description
1 hereby affirm thss I am licensed unaer provisions of Chapter 9(commencing p
nZja viNScdan701k1)il ofDiviaion3ofthcDow.and ProfessionsCode.anitmyhocnseis WSHR&DRYR RETROFTS,KTCHN&BTH CBNT & CNTR TOP
D'p: %K�� sees unt "` Lic8 UPGRD; DCTLESS SPLT SYS; HVAC RETROFIT
=p Dau Comrsctor
WW77 ARCHITECTS DECLARATION
1 understand my plaru shall m used as public reenNs
U
le C Licensed Professional
''0 OWNER-BUILDER DECLARATION
i�Y 1 bcmby aRhm that 1 am ucmpr from the Contractors License Law for the
COO following mason.(Section 7871.5.Bueamas and Professions Code:Any city Or county
which requires A Permit to cnnsuuct,aiur.improve,dcmollsh,or spear any stnemm
0.W its issuance.also a,m.da.pplicant for such permit to fileasignedsuemem
E G
that heulimmiedpursuantmd¢provisionsattheContractor'sLiccvclAw(Chapter9 Sq.Ft.Floor Area Valuation
e�$ (commencing with Section 7000)of Division 7 of dw Bushiness and Professions Cede)or $3900
Q�� that W is uempt themfmm and the pais for the iduged esempdon.Any violation or
Sctimn 7071.5 by any applicant for a permit subjects the applicant W a civil penally,a ypr�j,Number Occupancy Type
rot come dart five bmtdied dollar(SSl10L 3 6 9 010 21 .T 6J
L u owrcr of the prolmnY,m my employs with wage u nde'v(Sec.
044.Berko,
will daImwons andthe mumure Ianot me,Lnded, aw dosseta(Sec.heIa,Buaimu
and any wh bis Code:a,m canuuton, ndwhe law dam trot apply lf an awns,is Required Inspections
propertywhobuilds mimprowachicon,andwho dsatinum M1i whitened
his
Own employs,provided pr suersimprovemMaiartne yearn of malreud for tale U.
howsm. minis ofsti Otissoldwithal of yeararcapmacfrn.theowrv-
milder will ace eta Wrders of stirring cul m did not build m improve(m purpose of
uWJ.
0 I.u owner of the pmpeny,am eulukvely contracting with thorned contractors W
sou mut the Project(Sec.70se,Buinru and Piefesim.Code:)The Connemrs Li-
eco a Law ds not apply to an ower or property who builds or improwm thereon,and.
who canvacts for such projects with a onuactm(s)licensed Indonesia in em Commissars
Llceme Law.
❑TcmuemptunderSea .B&PClmthismssoe
Owns Das
WORKER'S COMPENSATION DECLARATION
I hereby M.ands,penally of peeury one of the fallowing daloruions:
I award will maintain a Certificate of Consent W self-imus in,Wmkers Comprn
cation.ss provihd for by Section 7700 of the labor Code.for the perfoommes of the
wort for which this permit is issued.
❑I have and will maintain Workers Compensadan lawsuits.as required by Section
37M the Maher Code,for the performance of the wok for which this per eii is issued.
My Workers Compensmom I nuruce carrier and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectio head not m completed if the permit Is fin e=hundred dollen(SIM)
or Was)
I cesdfy met in de performance of the work IDI which this Permit u Issued,l mall nm
employ anyperion in my mangier so as W bcome subject W the Wartera'ComPcuation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL Offer making this Cenificau of Excmpsion;you should
become subject W the Workch Compensation provisions of the lair Coda you amt
0 O forthwith ca.,Iy with such provisions m this permit shall m deemed.1md.
z.^N., CONSTRUCTION LENDING AOFNCY
'r+ IherebyalNm that Nem Is a couvunion leniingagency for the pmfarman¢of
(Yi the work for which this permit is issued(Sec 3091,Civ.C)
W Q Lenders Name ,
Z lenders Address
U O 1 easily that 1 haw mad this application tad sate hh d the amve irdomaeun is
DO corm I agree w comply with all city and county aNlnsnces aid sum laws mlating to
0 Wilding convection,and hereby sueariae representatives of this city W enter upon the
Lg7 above-mendoned property for inspection purposes
G (We)agree to save.indemnify and keep amerss tie City of Cupertino against
I--
VI liabilities.judgments.coca and expmues which may in any way a cmc against said City
U Z in coucqucnce of the granting of Nis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature or ApplicaneContractor Date
HAZARDOUS MATERIALS DISCLOSU RE Type of Roof
Will f applicant or fuhume building Occupant use or handle huudous material
ss defined by the Cupenme Municipal Code.aspmr 9.12 tad the Health and Safety
Code.Sachian 25532(+)7 - All roofs shall be inspected prior to any roofing material being installed.
❑Yea 0 N
Will the applicant or few.building accvFud use equipment or Join which If a roof is installed without first obtaining an inspection,I agree to remove
iI hxrudrus air contaminates as defined by the Bay Arca Air Quality Management all new materials for inspection.
District
❑Yca ON.
L haw mad the arntln w materials mquanrms maker Caper 6.95 of ft Calilm.
nu Health&SafcsyCods,Suctions 25.Sf15,MYO shad 25534.1 undemshN that irthe 6Wlthng .
ds mot currency haw a mnant.the It is my responsibility W nacfy de ocemm,of de
requirements which meso icon priors hamance or a Ccruruate of Occupancy. Signature of Applicant Date
Comm,ormmodvcdagent Date All roof coverings to be Class'W'or better
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 36901021 . 101
DATE ISSUED. . . . . .. : 10/13/2008
RECEIPT # . . . . . . . . . : BS000006332
REFERENCE ID # . . . : 08100068
SITE ADDRESS . . . . . : 20350 STEVENS CREEK BLVD APT 1
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PROMETHEUS REAL ESTATE GROUP
ADDRESS . . . . . . . . . . : 1900 S NORFOLK ST STE 150
CITY/STATE/ZIP . . . : SAN MATEO, CA 94403
RECEIVED FROM . . . . : ORION FINANCIAL SVC
CONTRACTOR . . . . . . . : STEVE WHITESIDES LIC # 29564
COMPANY . . . . . . . . . . : ORION FINANCIAL SERVICES
ADDRESS . . . . . . . . . . : PO BOX 693
CITY/STATE/ZIP . . . : ROSEVILLE, CA 95678
TELEPHONE . . . . . . . . : (916) 789-8484
• FEE ID .UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- - --------- ----------
1BSEISMICR VALUATION 3 , 900 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1ELECINSP HOUR 1 . 00 122 . 38 0 . 00 122 .38 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
1MECHINSP HOUR 1 . 00 122 . 38 0 . 00 122 . 38 0 . 00
IMPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
IPLMBINSP HOURS 1 . 00 122 .38 0 . 00 122 . 38 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
TOTAL PERMIT 530 . 80 0 . 00 530 . 80 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
---------------- --------------- --------------------
CREDIT CARD 530 . 80 AMEX
---------------
TOTAL RECEIPT 530 . 80
•
of/ o � � � �
CITY OF CUPERTINO BUILDING PERMIT APPLICATION
• E-Mail ORION(d-)SUREWEST.NET
Jobsite Address: 20350 STEVENS CREEK BLVD Date: 8/27/08
APT 101
Owner's Name:PROMETHEUS REAL ESTATE GROUP
Phone No.:(408)253-7100
APN # : 369-01-02�, ) Project Valuation: $3900.00
Blg. Permit Information: Bldg. ■ Elec.■ Plumb.■ Mech.■
JOB DESCRIPTION
Washer and Dryer Retrofits; Kitchen and Bath cabinet and counter-
top upgrade. Ductless split system;HVAC Retrofit.
CONTRACTOR INFORMATION
• Company:ORION DEVELOPMENT Phone:(916)789-8484
Contact Name: STEVE WHITESIDES Fax:(916) 789-1051
Address: P.O. BOX 693
City, State, and Zip:Roseville. CA 95678
State Contractors License: 747992 Exp. Date:9-30-2009
Worker's Comp.# : 238-0002445-07 Carrier:STATE FUND Exp. Date: 4-1-2009
Cupertino Business License#:
CREDIT CARD INFORMATION
Credit Card# 'No w"Imm
Name on Card: Orion Financial Services Inc.
Expiration Date: 01/12
Visa ❑ MasterCard ❑ Discover ❑ American Express ■
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