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07030338 F CUPERTINO 777. PERMIT BUILDING DIVISION PERMIT NO. BUILDING ADDRESS: OINSMP -LueihEiE BE �NVRUMhTHhU_9_=AGEM= 1040 MIMERCIAL ST. SUITE sAWQW2007 CONTROL NO. 1 r)0 IN-4.-0 8W 1/ 44-.---959 13UILDING PERMIT INFO ARCHMCTIENGINEER; BLDG ELECT PLUMB MFCH Z LICENSED CONTRACTOR'S DECLARATION )0 Job Description 0 p I hereby affirm that I am licensed under provisions of Chapter 9(commencing 'iU with Section 70(X))ofDivision 3 ofthc Business and Professions Code,and my license is in full force and effec Li en cl Lic.X..Q4t3q[ 09 FIRE DAIIAGE 2 X 4 BATHROOM, SUBFLOOR, UMDERFLOOR D.de-!4�, Cra ��WMZ C(A ARCHITEC717S DECLKR—ATION PLUMBING LIKE FOR LIKE. I understand my plans shall be used as public records U L Licensed Profcssional OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the z 0 following reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improvc,demolish,or repair any structure prior it)its issuance.also requires the applicant for such permit to rile a signed statement that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law(Chapter 9 Sq.Ft.Floor Area Valuation a ode)or (commencing with Section 70DO)of Division 3 of the Business and Professions C that he is exempt therefrom and the basis for the alleged exemption.Any violation of $6850 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not mom than five hundred dollars(M). 0 1,as owner of the property.or my employees with wages as their sole compensation, 31602094 , 01 will do the work,and the structure is notintended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:'Me ConLractoes License Law does not apply to an owner of property who builds or improves thercon,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 for purpose of sale.). C3 1,as owner of the property,am exclusively conuacting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractoes Li- conse Law does 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 1 am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSA71ON DECLARATION Aft I hereby affirm under penalty of pedury one of the following declarations: IN have and will maintain a Certificate ofConsent to self-insurc for Worker's Compcn- �Ation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ;AIVI 0 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 Workces orn nsad d Policy number am* fA I 1?y L-C Policy No.: -0 MX=an I CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed ifthe permit is forrine hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manncr so as to become subject to the Workcrs'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 Z forthwith comply with such provisions or this permit shall be deemed revoked. 0 CONSTRUCTION LENDING AGENCY I hereby affirm that them is a construction lending agency for the performance of > the work for which this permit is issued(Sec.3097,Civ.C.) Lender's Name Lcndees Address z 1 certify that I have read this application and state that the above information is CorrccL I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize reprcscntafivrs or this city to enter upon the U above-mcndoncd property for inspection purposes. W (We)agree to save,indemnify and keep harmless the City of Cupertino against C14 c against said City v) liabilities,judgments,costs and expenses which may in any way accru Z in consequence of the granting of this permit. Date APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCER TIONS IEGV 7 Je_J?_ �J Re-roofs Signature ot—Appli—cant/Conha" [_ [Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Munici ode,Chapter 9.12,and the Health and Safety Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. 0 Yes 7 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 hazardous air contaminants as d fi d by the B y Area Air Quality Management all new=terials for inspection. �Istrict? Yes e�7 a I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,sections 25505.25533 and 25534.1 understand that if the building does not currently have a tenant,that it i my Ibility to nouty the occupant or the requirement%which met prior to issu a Certificate of Occyp- Signature of Applicant Date 3,jplul All roof coverings to be Class"B"or better Owner or authori7zd agent Dbtc CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: suew COPY # Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . 31602094 .01 DATE ISSUED. . . . . . . 03/29/2007 RECEIPT #. . . . . . . . . BS000000821 REFERENCE ID # . . . : 07030338 SITE ADDRESS . . . . . 20200 LUCILLE AVE #111 SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . PRCMETHEUS MANAGEMENT ADDRESS . . . . . . . . . . 20200 LUCILLE AVE # 111 CITY/STATE/ZIP . . . CUPERTINO, CA 95014 RECEIVED FROM . . . . RECEIPT INTERFACE CONTRACTOR . . . . . . . HENRY DEVERA LIC # 24605 COMPANY . . . . . . . . . . DE'�ERA CONSTRUCTION INC. ADDRESS . . . . . . . . . . 1040 COMMERCIAL ST. SUITE 108 CITY/STATE/ZIP . . . SAN JOSE, CA 95112 TELEPHONE . . . . . . . . (4C8)441-9598 FEE ID UNIT QUANTITY JTMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- -------- ---------- ---------- ---------- BPERMFEE VALUATION 6, 850 . 00 137.16 0 . 00 137 . 16 0 .00 BSEISMICRE VALUATION 6, 850 .00 0. 70 0 .00 0 . 70 0 . 00 PPERMITFEE FLAT RATE 1 .00 38 .37 0 .00 38 .37 0 . 00 -- -------- ---------- ---------- ---------- TOTAL PERMIT 176 .23 0 . 00 176 .23 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 176 .23 M/C DEL TOLAND --------------- TOTAL RECEIPT 176 .23 CITY OF CUPERTINO 0--of PERMIT APPLICATION FORM CUPEkTINO APN ate: 3 o Building Address: Ai Mailing Address (if di erent from building address): DzL,0 0 L., 1.41, ,.4hone 0 er's Name: I ontractor License ft: �J)01P_U�� (2i- �*(' :12 T�i-) L* ense#: �C�acti 1Jhone:"-(0', -VL).,) Cupertino Business ic 0 VeA .. TLA Fax: Building Pennit Info: Bldg Elect El Plumb Mech El Job Description: LTatL� A,7,a a-)(-14 (A t-Al-A4y\'- Commercial-n LJ, 4k, I V Residential El lilAr—j— no Sq.Ft.: Sq.Ft. Floor Area: "�-- o 'r, Cost of Project- k)j Occupancy Group: Type of Constriiction: Please check this box if the project is a czW— second-story addition: El Project Size: Standartg-,�" Large El Major El Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances___ MECHANICAL BBOILER1 Bo�ler<= 100,000 Btu MECHANICAL BBOILER2 Boile-> 1 OOK to 5 OOK Btu MECHANICAL BBOILER3 Boil,-r> 500K to IM Btu MECHANICAL BBOILER4 Oiler> IM to 1.75 M Btu MECHANICAL BBOILER5 Boller> 1.75M Btu MECHANICAL BCONSTAX 1-onstruction Tax BUILDING BCONSTAX in,l/off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Co astax-Resi/Mobi I e BUILDING BELEC1000 El cc 600V<= I OOOA ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD I,'-nergy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING of 3 CITY OF CUPERTINO MY OF PERMIT APPLICATION FORM CUPEkT INO Quantit Fee ID �ee Description Fee Group (f BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM —New Comm Mechanical MECHANICAL BNUCOMMP N,-w Comm Plumb PLUMBING BOVERTIME In,;pection Overtime BUILDING BPBACKFLOW Atriospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMB"TXTG BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee — BUILDING BPLANCKADD Pla:.i Check Add Multi BUILDING BPLANCKREP Plan Check BUILDING BPREPIPE Repipe Of Fixtures PLUMBING BPSEWAGE S,ewaRe Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK LaNn Sprinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT A't of Drain &Vent PLUMBING BPWATER Instf ill/Alter Water Pipe PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER (' Unit> 10,000 cfm MECHANICAL BREMAIR,HAN A/C Units <= 10,000 cfm --MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN — Relocation of Furnace MECHANICAL BREMFURNOV — elt) Furnace> 1 OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Initallation of Hood MECHANICAL BREMMISC __M1.sc Apparatus ELECTRICAL BREMNRAPP Rery-Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BRIF,MPOWER Powi.-r Device/Apparatus ELECTRICAL BREMRFCEPT Reptl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMDEPALT R(,pair/Alter Heating MECHANICAL BREMRESAPP Reriodel Res Appliance ELECTRICAL 2 of 3 Community Development 10300 Torre Avenue Cupertino CA 95014 -3228 Telephone(408)777 Fax(408)777-3333 01YOF CUPEkTINO Building De artment JOB ADDRESS: PERMIT # *ZL Q-0 d . I I � 7� 0 -7 OWNER'S NAME: W-0-69t" PHONE # 'f63-ff GENERAL CONTRACTOR:� FAX#Ltd I am not using any subcontractors: Signature ate Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing ooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile (_0 9N 6w- ner-rContractor Si��tu�re � --7 bate