10090202CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22601 VOSS AVE CONTRACTOR: CITY FACILITIES PERMIT NO: 10090202
OWNER'S NAME. CITY OF CUPERTINO 10300 TORRE AVE DATE ISSUED: 02/18/2011
OWNER'S PHONE: 4087773212 CUPERTINO, CA 95014 PHONE NO: (408) 777-3228
I
—+0—R DESCRIPTION: RES COMMERCIAL
0 LICENSED CONTRACTOR'S DECLARATION iDiNTiAT
License Class Lic. #
Contractor
Date
I hereby affirm that I am licensed under the provisions of Chapter 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 for which this
permit is issued.
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,
Signature- — Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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)
1, 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.
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 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, I 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.
INSTALL & OPERATE HYDROGEN GENERATOR.
1NCREASE
USED
IN AN AIR MONITORING TRAILER
Sq. Ft Floor Area: I Valuation: $2000
I APN Number: 34215038,00 1 Occupancy Type: I
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. 1 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 I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505,25533, and 25534.
Owner or authorized ag Dte,"�7-0Z--�f
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 (See. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
1 4:,Vj FEE ESTIMATOR - BUILDING DIVISION
AD1
1 1
D BY:
*VALUATION:
1$2,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: New Construction
_ PRIMARY
USE: Commercial Building
7Reli2ious activities
in BQ zone? 0 Yes
0 No
PENTAMATION
PERMIT TYPE: lul
-A
OCCUPANCY TYPE:
TYPE OF
CONSTR.
U (Private Gar/Ag Bldg) J
I I M.1 WIM
M,,�ch, Plan 111"anh. plarl Plan Check
Pcnnii Fo: 11crMil h�nmit Pea:
Othct Ihwh, Irzv,. 011,'i?r plwnb fylsjp. Elec
Hc,,ch, Insy, Fc,,. ?w1h, Insp, 1,10c, In rt f"ec:
NOTE: Thesefees are based on the preliminary information available and are only an estimate Contact the Dept for addnl info.
FEE ITEMS ffee Resolution 09-051 Eff. 711/1J0
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: ISUPPKFEE
$0.00
[= #
$158.001
Electrical
IBREMPOWER I Generators
Suppl. PC Fee: E) Reg. 0 OT:=hrs
$252.00
PME Plan Check:
$0.00
Permit Fee: ISUPINSFEE
$0.00
Suppl. Insp. FeeO Reg. 0 0TF1_-_61
hrs
$126.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Constr. Tax: IBCONSTAXC
$0.00
Acoustical Fee: 0 Yes (E) No
$0.00
0
E)
Work Without Permit? 0 Yes E) No
$0.00
plmnjngFee:
$0.00
Select a Non -Residential
1 Building or Structure
0
0
Travel Documentation Fee: I TRA VDOC
$42.00
Strong Motion Fee: IBSEISMIC0
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
$UBTOTALS,,,
$421.501
$158.00
TOTAL FEEt
F $579.50
Revised: 9/14/2010