10120172 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10070 PASADENA AVE CONTRACTOR:BRYAN GROVER C AND PERMIT NO:10120172
LAURA B TRUSTEE
OWNER'S NAME: BRYAN GROVER C AND LAURA B TRUSTEE 10070 PASADENA AVENUE DATE ISSUED:01/27/2011
OWNER'S PHONE: 4082577500 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALE]
License Class Lie.# INTERIOR ALTERATION-ADD 48 LINEAR FEET,NEW
PARTITION,ADD 5 NEW ELECTRICAL OUTLETS,ADD 5
Contractor Date NEW
I hereby affirm that I am licensed under the provisions of Chapter 9 HAND SINKS,NO STRUCTURAL,NO REROOF.
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificatebf 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. Sq.Ft Floor Area: Valuation:$12500
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35717033.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the et
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:,
with all non-point source regulations per the Cupertino Municipal Code,Section f
9.18.
RE-ROOFS:
Signature Date 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 all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(See.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections;5505,25533,and 25534.
B'407 0
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized age Dat .
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
Jow
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed rev ked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION MW Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as or lic records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point so ce regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10070 Pasadena Ave DATE: 04/16/2013 REVIEWED BY: Sean
APN: BP#: �� VALUATION: $0
7
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1GENCO i
WORK Unreasonable Hardship Form
SCOPE
Itifech.flan Check Pksmb.Plum Check E1ec_.Plan Check
Mech.PeraIII Fee: Plumb.Permit Fee: Ekc.Permit Fee:
Other-Hech.Insp., Other Plumb Insp. Li Other Elec.Insp. Lj
V ch.Lnsp.Fee: Plumb. Insp.Fee: Elec.Insp.Fee:
!NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
''District,eta). These ees are based on the relimina information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl.PC Fee: (D Reg. Q OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee-(F) Reg. ® OT0 0 hrs $0.00
PME Unit Fee:. $0.00
PME Permit Fee: $0.00
Construction Tax:
Administrative,.Fee:
Work Without Permit? C) Yes 0 No $0.00
Advanced Planning Fee. $0.00 Select a Non-Residential
Trca,el Documentation}ices: Building or Structure 0
i
Strong Motion'Fee.: $0.00 1 # Accessibility Hardship Exemption
Bldg Stds Commission Fee: $0.00 $174.00 1ACCHRDE
SUBTOTALS: $0.00 $174.00 TOTAL FE
E 1 $174.00
Revised: b4/01/2013