10120036I CITY OF C-1 PERTINO BUILDING PERMIT
IBUILDING ADDRESS: 20863 STEVENS CREEK BLVD I CON TRUCTOION INC EHMAN I PERMIT NO: 10120036
I OWNER'S NAME: MATfIESON REALTY SERVICES INC 1932 EUCALYPTUS AVE I DATE -ISSUED: 01/05/201.1
OWNER'S PHONE: 6508021800 SAN CARLOS, CA 94070 PHONE NO: (650) 593-6211
❑ LICENSED CONTRACTOR'S DECLARATION
License Class L7 OC/— 9 Lic. # &2 793 �p
Contractor f�il!%fQ�J L�%i{ Zg Date drbl
I hereby affirm that I am licensed under the provisions of hapter 9
(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 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 by
Section 3700 of the Labor Code, for the performance of the work fh this
permit is issued. ,
APPLICANT CERTIFICATION V "
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of s permit. Additionally, the applicant understands and will comply
with all nt so}�ce regulatio the Cupertino Municipal Code, Section
9.18. JJ) ��
Date S
❑ v OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 (Sec.7044,
Business & Professions Code)
I; as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
I 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 by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
1 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 Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked.
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
BUILDING PERMIT INFO: BLDG F_ ELECT F_ PLUMB F_
MECH F_ F_ F_ COMMERCIAL F_
JOB DESCRIPTION: STE 275 - DEM[SING SPACE, BUILD FULL HEIGHT
PARTITION WALL
Sq. Ft Floor Area: I Valuation: $800
APN Number: 36232053.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
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.
Signature. of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Codg sections 25505, 25533, and 25534.
Dater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
understand my plans shall be used as public records.
Signature.
Date
Licensed Professional
FM_7
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20863 Stevens Creek Blvd 075 1 DATE: 12/07/2010
REVIEWED BY: larry s
APN:
BP#:
'VALUATION: $800
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial BuildingIY)C11L
USE:
IGOUh ,1R,
PENTAMATION 16 TI
PERMIT TYPE:
WORK
add demisinq wall 10 feet long.
SCOPE
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
B (Tenant Improvements)
II-B,III-B,IV,V-B
0
$0.00
$0.00
TOTALS:
0
$0.00
$0.00
MECH, HOURLY 0 Yes (F) No
PLUMB, HOURLY 0 Yes, 0 No
ELEC, HOURLY 0 Yes, 0 No
WCJ?. Plan CheckT-T
phoob, Plurt C. riw(
EIPC:. Non Check
R4ech. Purnell FI-.
Plrr,nir. Penii1 F,e:
Other Alach. Insp-
orho• Pl,ru r !rLi
Usher (,'Ict . Imp,
fec h. /nsp. Feel"
P,'remh hesr,. I • t
/Joc. Insp.
NOTE: These fees are based on the preliminary, information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 09-051 Eff. 7/1/10)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
1SUPPKFEE
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: 0 Reg. 0 OT
2.0
1 hrs
$252.00
PME Plan Check:
$0.00
Permit Fee: ISUPINSFEE
$0.00
Suppl. Insp. Fee.0 Reg.
0 OT
2.0
hrs
$252.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax
Acoustical Fee:
0 Yes 0 No
$0.00
0
0
Work Without Permit? 0 Yes 0 No
$0.00
Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
0
0
i
Truvel Documentation Pyres.
Strong Motion Fee:
IBSEISMICO
$0.50
L2.5 hrs
$39.00
Admin./Clerical Fee
1ADMIN
Bldj4 Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$505.50
$39.00
TOTAL FEE:
$544.50
Revised: 11/08/2010