10040041 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20350 STEVENS CREEK BLVD APT 502 CONTRACTOR:ORION FINANCIAL PERMIT NO: 10040041
SERVICES
NER'S NAME: PROMETHEUS REAL ESTATE GROUP PO BOX 693 DATE ISSUED:04/06/2010
OWNER'S PHONE: 4082537100 ROSEVILLE,CA 95678 PHONE NO:(916)789-8484
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT r— PLUMB r
License Class Lic.#
MECH F RESIDENTIAL I- COMMERCIAL
Contractor Date
JOB DESCRIPTION:WASHER&DRYER RETROFITS;KITCHN&BATH CBNET&
I hereby affirm that I am licensed under the provisions of Chapter 9
COUNTER-TOP UPGRADE.DUCTLESS SPLIT SYSTEM;HVAC
(commencing with Section 7000)of Division 3 of the Business&Professions
RETROFIT
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 Sq.Ft Floor Area: Valuation:$3900
permit is issued.
APPLICANT CERTIFICATION APN Number:3690102LAPT502 Occupancy Type:
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 regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
-ature 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
I,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,
Signature of Applicant: Date:
Business&Professions Code)
I,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: HAZARDOUS MATERIALS DISCLOSURE
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 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&Safety Code,Sections 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 Owner or authorized agent:
Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
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
the above mentioned property for inspection purposes.(We)agree to save
.mify 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
CITY OF CUPERTINO
9 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36901021.APT502
DATE ISSUED. . . . . . . : 04/06/2010
RECEIPT #. . . . . . . . . BS000010114
REFERENCE ID # . . . : 10040041
SITE ADDRESS 20350 STEVENS CREEK BLVD APT 5
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER PROMETHEUS REAL ESTATE GROUP
ADDRESS 1900 S NORFOLK ST STE 150
CITY/STATE/ZIP . . . : SAN MATEO, CA 94403
RECEIVED FROM ORION FINCL SVCS IN
CONTRACTOR STEVE WHITESIDES LIC # 29564
COMPANY . . . . . . . . . . : ORION FINANCIAL SERVICES
ADDRESS PO BOX 693
CITY/STATE/ZIP . . . : ROSEVILLE, CA 95678
TELEPHONE (916) 789-8484
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
IBCBSC 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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- --------------
100 FOOTINGS 102 PIERS
104 REBAR 301 ROUGH PLUMBING
302 TUB & OR SHOWER 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 305 FRAME
307 INSULATION 308 SHEETROCK
C)
CITY OF CUPERTINO BUILDING PERMIT APPLICATION
E-Mail ORION(a2SUREWEST.NET
Jobsite Address: 20350 STEVENS CREEK BLVD Date: 10/30/09
APT 502
Owner's Name:PROMETHEUS REAL ESTATE GROUP
Phone No.:(408)253-7100
APN#: 369-01-02 (� j'��/ Project Valuation: $3900.00
Big. Permit Information: Bldg. ■ Elec.■ Plumb.■ Mech.■
JOB DESCRIPTION
Washer and Dryer Retrofits; Kitchen and Bath cabinet and counter-
top upgrade. Ductless split system;HVAC Retrofit.
CONTRACTOR INFORMATION
Company:ORION DEVELOPMENT Phone:(916)789-8484
Contact Name: STEVE WHITESIDES Fax:(916)789-1051
Address: P.O. BOX 693
City, State, and Zip:Roseville. CA 95678
State Contractors License: 747992 Exp. Date:9-30-2009
Worker's Comp.#: 238-0002445-07 Carrier:STATE FUND Exp. Date: 4-1-2010
Cupertino Business License#:
CREDIT CARD INFORMATION
Credit Card#: 4246 3151 4062 7744
Name on Card: Orion Financial Services Inc.
Expiration Date: 01/13
Visa 0 MasterCard 0 Discover ❑ American Express M