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10050105 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20350 STEVENS CREEK BLVD APT 403 CONTRACTOR:ORION FINANCIAL PERMIT NO: 10050105 SI RVICES ✓NER'S NAME: PROMETHEUS REAL ESTATE GROUP PO BOX 693 DATE ISSUED:05/11/2010 OWNER'S PHONE: 4082537100 ROSEVILLE,CA 95678 PHONE NO:(916)789-8484 la LICENSED CONTRACTOR'S DECLARATION p oG Y BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# L�'7 7 n f 7 / l7 MECH r- RESIDENTIAL f- COMMERCIAL Contractor �)2 f/V Date J IV f I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:WASHER&DRYER RETROFITS;KITCHEN&BATH (commencing with Section 7000)of Division 3 of the Business&Professions CE.BINET& Code and that my license is in full force and effect. COUNTERTOP UPGRADE.DUCTLESS SPLIT SYS;HVAC RI TROFIT 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. Sq.Ft Floor Area: Valuation:$3900 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:36901021.APT403 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. C n ature S Date —b/ho Is:ued by: G t '' 1 ,�' ��—/� Date: �' ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: Al roofs shall be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to Sit nature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). — I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I 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 performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Sa ety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. 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. Ov n �o'nze /f_-rt: /` � Date: a� APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I h xeby affirm that there is a construction lending agency for the performance of work's t-' •ilding construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) he above mentioned property for inspection purposes.(We)agree to save Le ider's Name inuemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Le ider's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point so ce regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CL rPERTINO CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # Date: Building Address: <\ &V\- �:�1 ' Mailing Address (if different from building address): Are Hazardous Materials being used as part of this pt oject? Yes No ❑ HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Own (s`Na i ' , 4 Phone Contrackor: Phone: v r �� Fax: Contractor License#: Cupertino Business License#: 4 Contact: Phone: Fax: Residential 0 Commercial Job Description: k_ 6,--:" � F Building Permit Info: Bldg Cl--'' Elect L9 Plumb L ' Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A 1-B II/III/V-A II/III B, IV-HT, V-B 12/ - Valuation: Square Footage: Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.builditgreen,or Revised 07/14/09 SANA-11CITY OF CUPERTINO IY OF GENERAL BUILDING APPLICATION CUPEkTfNO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 w ndows) 1WINMEWSTR New Window-structural shear B wall/masonry (includes plan ck fee) IEPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical F ermit Fee M / 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Viechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone 1BCBSC Cal Bldg Sta:idards Commission Fee B ALL PERMIT TYPES ` 1BSEISMICR Seismic Residential B / 1BSEISMICO Seismic Corrmercial B 1TRAVD0C Travel & Dommentation B 1BUSLIC Business Lic--nse B ��(�C)L/ 5 of 5 CITY OF CUPERTINO 9 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36901021 .APT403 DATE ISSUED. . . . . . . : 05/11/2010 RECEIPT #. . . . . . . . . : BS000010378 REFERENCE ID # . • . : 10050105 SITE ADDRESS . . . . . : 20350 STEVENS CREEK BLVD APT SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PROMETHEUS REAL ESTATE GROUP ADDRESS . . . . . . . . . . : 1900 S NORFOLK ST STE 150 CITY/STATE/ZIP . . . : SAN NATEO, CA 94403 RECEIVED FROM . . . . : VITALIY TRUSH CONTRACTOR . . . . . . . : STEVE WHITESIDES LIC # 29564 COMPANY . . . . . . . . . . : ORION FINANCIAL SERVICES ADDRESS PO BCX 693 CITY/STATE/ZIP . . . : ROSE�;ILLE, CA 95678 TELEPHONE . . . . . . . . : (916) 789-8484 FEE ID UNIT QUANTITY AMCUNT 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 1ELECINSP HOUR 1 .00 126 . 00 0 . 00 126 . 00 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0. 00 1MECHINSP HOUR 1 . 00 126 . 00 0 . 00 126 . 00 0. 00 1MPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1PLMBINSP HOURS 1 .00 126 . 00 0 .00 126 . 00 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 ---- ------ ---------- ---------- ---------- TOTAL PERMIT 547. 50 0 . 00 547 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - ------------------- CREDIT CARD 547. 50 VISA --------------- TOTAL RECEIPT 547.50