11030152CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20755 STEVENS CREEK BLVD
CONTRACTOR: BALCH PETROLEUM INC
PERMIT NO: 11030152
OWNER'S NAME: STEVENS CREEK CUPERTINO ASSOCIATES
PO BOX 36I230
DATE ISSUED: 07/06/2011
OWNER'S PIIOIYE: 8002687021 _ .._. __...... ., _..._... _... --__
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PHONE NO.1408)942-8686- -
LICENSED CONTRACTOR'S DECLARATION
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INFO:
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BUILDING PERMIT BLDG ELECT PLUMB
License Class Lic. #
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Contractor�g2G�.} Yei¢Gt,_ AA Date
MECH RESIDENTIAL COMMERCIAL
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: DEMO OF GAS STATION(FUEL DISPENSING STATION)
(commencing with Section 7000) of Division 3 of the Business & Professions
INCLUDING ALL FUEL COMPONENETS (UST'S, DISPENSERS,
Code and that my license is in full force and effect.
PIPING). BUILDING AND CANOPY. ONLY PLANTERS &
I hereby affirm under penalty of perjury one of the following two declarations:
[ 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
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for b
Sq. Ft Floor Area:
Valuation: $45000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 32632056.00
Occupancy Type:
APPLICANT CERTIFICATION
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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non -point source re ulati per the Cupertino Municipal Code, Section
9.18.
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Signature \�... Date Off' D f
Issued b}✓ — Date.
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
Signature of Applicant: Date:
[, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
[ have and will maintain a Certificate of Consent to self -insure for Worker's
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued, I shall
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Health & Safee ections 25505, 25533, and 25534.
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
Lora.th;d nt:forthwith
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comply with such provisions or this permit shall be deemed revoked.
Date:
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
ARCHITECT'S DECLARATION
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
DEMOLITION
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
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ADDRESS: 20755 stvns crk blvd.
DATE:
E: 03/15/2011
REVIEWED BY: bobs.
APN:
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I BP#:
*VALUATION:
1$45,000
*PERMIT TYPE: Demolition Permit
P1. 4, __-V (.717E(W 7'� III., -.
PRIMARY Commercial Building
USE:
PENTAMATION 1COMMLDEM
PERMIT TYPE-:.-
woRK
demo exisiting fuel dispensing station, and fuel components.
SCOPE
FEE ID FLR AREA
(s.f.)
1DEMOCOM 13,000
Efec flall C ka L
NOTE. These ees are based on the prefindnary inforination available and are only an estimate. Contact the Deptfor addn 7 info.
FEE ITEMS (Fee Resolution 09-051 Eff 711110)
FEE
QTY/FEE
MISC ITEMS
plal;
Permit Fee:
$1,519.00
Suppl. Insp. Fee.0 Reg. 0 OT
0.0
hrs
$0.00
('Aw Fee:
;1<owtrii."d P�- 2-
Work Tvilhout l'o-niii",
Fey is
Strong Motion Fee: IBSEISAgCO
$9.45
Select an Administrative Item
1
Bldg Stds Commission Fee:, IBCBSC
$2.001
. .. ISUBTOTALS:
1 $1,530.451
$0.001 TOTAL FEE:
.45
Revised: 01/15/2011