10040026CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: x.9772 STEVENS CREEK BLVD CONTRACTOR: TBD - TO BE
DETERMINED
WNER'S NAME: EVERSHINE VI LP
OWNER'S PHONE: 4083431088
❑ LICENSED CONTRACTOR'S DECLARATION
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.
;nature
Date
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).
JOB DESCRIPTION: RESIDENTIAL
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
building construction, and hereby authorize representatives of this city to enter
rn the above mentioned property for inspection purposes. (We) agree to save
demnify 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. A -A
02 e
INSTALL SIGN
Sq. Ft Floor Area:
PERMIT NO: 10040026
DATE ISSUED: 04/05/2010
PHONE NO:
COMMERCIAL
Valuation: $2000
APN Number: 36906009.19772 I Occupancy Type: I
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: �X-14 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 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 agen/t;. _
Date. v �
G -
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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
PERMIT RECEIPT OPERATOR: SylviaM
5 ITEMS OF 5 COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36906009.19772
DATE ISSUED.......: 04/05/2010
RECEIPT #.........: BS000010101
REFERENCE ID # 10040026
SITE ADDRESS .....: 19772 STEVENS CREEK BLVD
SUBDIVISION .......
CITY .............. CUPERTINO
IMPACT AREA ......
OWNER EVERSHINE VI LP
ADDRESS 19772 STEVENS CREEK BLVD
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM GARY CHIEN
CONTRACTOR TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS ..........
CITY/STATE/ZIP
TELEPHONE ........:
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT
AMOUNT
---------------
127.63
---------------
127.63
VOICE ID DESCRIPTION
-------- ---------------- -----------
101 FOUNDATION
REFERENCE NUMBER
--- ----------------
101
VOICE ID DESCRIPTION
-------- ----------------------------
103 UFER
104 REBAR 105
304 ROUGH ELECTRICAL 505
ANCHOR BOLTS
FINAL ELECTRICAL
AMOUNT
PD -TO -DT
THIS REC
BAL
FEE ID
UNIT
QUANTITY
---------NEW
1BCBSC
-------------
VALUATION
----------
2,000.00
1.00
0.00
0.00
1.00
0.63
0.00
0.00
1BSEISMICO
VALUATION
2,000.00
0.63
42.00
0.00
42.00
0.00
1EPERMITFE
FLAT RATE
1.00
100
42.00
0.00
42.00
0.00
1ESIGN
UNITS
.
1.00
42.00
0.00
42.00
0.00
1TRAVDOC
FLAT RATE
127.63
0.00
127.63
0.00
TOTAL PERMIT
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT
AMOUNT
---------------
127.63
---------------
127.63
VOICE ID DESCRIPTION
-------- ---------------- -----------
101 FOUNDATION
REFERENCE NUMBER
--- ----------------
101
VOICE ID DESCRIPTION
-------- ----------------------------
103 UFER
104 REBAR 105
304 ROUGH ELECTRICAL 505
ANCHOR BOLTS
FINAL ELECTRICAL
CITY OF CUPERTINO
�� SIGN
CUPEkTINO PERMIT APPLICATION FORM
0.12W.H..
APN # t G�'7 �.
Date:
14
t
Building Address:
1 ( C
L r � 1A0 CSA
Mailing Address. (if different from building address):
Owner's Name: evey-j hI n e V I F
Phone #: ( Lj0&)
Contractor:
A P K S
Phone #: 61-6 —44k—((t6
Fax #: 64-49�—((�[
Contractor License #. ' V; (
((
Cupertino Business License #:
Contact:
C kv-t,(t,� (k t
Phone #: 6
Fax #: 6 W
o
Building Permit Info.
Bldg ❑ Elect ❑ Monument
❑ Mounted on Building
Residential ❑ Commercial
Job Description:
Valuation (cost of project):
Project Size: Express ❑ StandardR[ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 07/06/09
CITY OF CUPERTINO
al SIGN
CUPEkTiNO FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
1 SIGNDIRECT
Directional
B
1 SIGN/RF
Ground/Roof/Projecting Signs
B
1 SIGNMASCK
Master Plan Sign Check
B
1 SIGNREWRKG
Rework of any existing Ground
Sign
B
1 SIGNOTHER
Other Sign
B
1 SIGNREINSP
Re -inspection Fee
B
1 SIGNWNONEL
Wall/Awning Sign, Non-
Electric
B
1 SIGNWELEC
Wall, Electric
E
IESIGN
Sign, Outline Lighting System
or Marquee supplied from one
branch
E
10EAP5
1ESIGNADD
Additional Branch Circuit on
Same Sign, Outline System or
Marque
E
10EAP6
1 ELCPLNCK
Plan Check Fee
E
I
1 EPERMITFEE
Electric Permit Fee
E
1 BCBSC
Cal Bldg Standards Commision
Fee
B
ALL PERMIT TYPES
1BSEISMICOM
Seismic Commercial
B
1 BSEISMICRE
Seismic Residential
B
1TRAVDOC
Travel & Documentation
B
1 BUSLIC
Business License
B
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