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09010117 CITY OF CUPERTINO BUILDING DIVISION PERMIT 1.� 1IYFI�llr BUILDING ADDRESS: PERMIT NO. 20350 STEVRNS CRETE RIA71D APT ORION OWN"GAME: PERMIT ISSUE DATE .O BE)HSA CONTROL NO. ARCHCTECT/ENGCNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH WSHR&DRYR RETROFTS KTCHN&BT o o LICENSED CONTRACTOR'S DECLARATION C BNT & CNTRTO P UPGRD Job Description m I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing O� with Section 7000)of Division 3 of the Business and Professions Code,and my license is =y in full force and effect Z License Class Lic•8 n_p Date Contractor e ',a ARCHrmc-rS DECLARATION 4 g-j I understand my plans shall be used as public records �W U. Licensed Professional n ti OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor s License Law for the in O 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 file a signed statement =G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y 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 APN Number Occupancy Type not more than five hundred dollars($500). ❑1,as owner of the property,or my employees with wages as their solo compensation, will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of q P 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 for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li. cense Law does not apply to an owner of property who(wilds or improves thereon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑I am exempt under Sea B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- ..ation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I 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 Workees Compensation Insurance carrier and Policy number arc: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is far one hundred dollars($100) or Icss.) I certify that in the performance of the work 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 ,J`f-, forthwith comply with such provisions or this permit shall be deemed revoked. 0 Z, CONSTRUCTION LENDING AGENCY Fr►�—e I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.) Wt_1,A Lender's Name ►7 z L.cndees Address U C) I certify that I have read this application and state that the above information is LL" correct 1 agree to comply with all city and county ordinances and state laws relating to O V building construction,and hereby authorize representatives of this city to enter upon the >4 U above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against ,..4 In liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. Date h APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIONS. Re-roofs Signature of Applicant/Contractor Dale Type of Roof HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cole,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. C]Yes ❑No Will If a roof is installed without first obtaining an inspection,I agree to remove ll the applicant or future building occupant use equipment or devices which L hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. strict? ❑Yes ❑No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building does not currently have a tenant that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a certificate of Occupancy. Signature of Applicant Date Owner or authorized agent Date IAll roof coverings to be Class" 'or better CITY OF CUPERTINO 9 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 36901021 .404 DATE ISSUED. . . . . . . : 01/27/2009 RECEIPT # . . . . . . . . . BS000007051 REFERENCE ID # . . . : 09010117 SITE ADDRESS . . . . . : 20350 STEVENS CREEK BLVD APT 4 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 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3 , 900 .00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 3, 900 .00 0 .50 0 . 00 0 . 50 0 . 00 lELECINSP 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 1MPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00 1PLMBINSP 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 531 . 80 0 . 00 531 . 80 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 531 . 80 VISA --------------- TOTAL RECEIPT 531 . 80 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------- 100 FOOTINGS 102 PIERS 104 REBAR 301 ROUGH PLUMBING 302 TUB & OR SHOWER 303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL 305 FRAME 307 INSULATION 308 SHEETROCK 01 of o i n CITY OF CUPERTINO BUILDING PERMIT APPLICATION �� E-Mail ORIONCa-SUREWEST.NET Jobsite Address: 20350 STEVENS CREEK BLVD Date: 40f09 APT 404 Owner's Name:PROMETHEUS REAL ESTATE GROUP Phone No.:(408)253-7100 APN#: 369-01-024, q`��, Project Valuation: $3900.00 Blg. Permit Information: Bldg. ■ Elec.■ Plumb.■ Mech.■ JOB DESCRIPTION 1x1 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#. Name on Card: Orion Financial Services Inc. Expiration Date: 01/12 Visa 0 MasterCard 0 Discover 0 American Express M