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09110001 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20350 STEVENS CREEK BLVD APT 301 SERVICES TOR:ORION FINANCIAL PERMIT NO:09110001 '`lER'S NAME: PROMETHEUS REAL ESTATE GROUP PO BOX 693 DATE ISSUED: 11/02/2009 ROSEVILLE,CA 95678 PHONE NO:(916)789-8484 OwNER'S PHONE: 4082537100 BUILDING PERMIT INFO: BLDG ELECT PLUMB 11 LICENSED CONTRACTOR'S DECLARATION License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION:WASHR&DRYR RETRFTS;KTCHN&BTH I hereby affirm that I am licensed under the provisions of Chapter 9 CABNT&COUNTR-TOP (commencing with Section 7000)of Division 3 of the Business&Professions UPGRD;DUCTLS SPLIT SYS;HVAC RETROFT 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. Valuation:$3900 1 have and will maintain Worker's Compensation Insurance,as provided for by Sq,Ft Floor Area: Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:36901021.301 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Date: 9.18. Issued by: F' ture Date RE-ROOFS: OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roo is 1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,as owner of the property,or my employees with wages as their sole compensation, Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: 1 have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 o the Compensation,as provided for by Section 3700 of the Labor Code,for the comHealth maintain pliancCaforniaewith the Cupertino municipal Code,Chapter 9 12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. 1 have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or authorized agent: Date: 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. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a constriction lending agency for the performance of work's 1 certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.l agree to comply with all city and county ordinances and state laws relating Lender's Name to hirilding construction,and hereby authorize representatives of this city to enter he above mentioned property for inspection purposes.(We)agree to save Lender's Address anify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 9 ITEMS OF 9 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36901021 .301 DATE ISSUED. . . . . . . : 11/02/2009 RECEIPT #. . . . . . . . . BS000009096 REFERENCE ID # 09110001 SITE ADDRESS 20350 STEVENS CREEK BLVD APT 3 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 FINANCIAL SVC 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- ---------- ------------- ---------- ---------- ---------- ---- 00 1BCBSC VALUATION 3, 900 . 00 1 .00 0 . 00 1. 00 0 • 1BSEISMICR VALUATION 3, 900 . 00 0 .50 0 . 00 0.50 0 . 00 lELECINSP 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 ------ -- ---------- ---------- ---------- -- 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 CITY OF CUPERTINO BUILDING PERMIT APPLICATION E-Mail ORIONCaD-SUREWEST.NET Jobsite Address: 20350 STEVENS CREEK BLVD Date: 10/30/09 APT 301 Owner's Name:PROMETHEUS REAL ESTATE GROUP Phone No.:(408)253-7100 �)ZV- 3 0% APN#: 369-01-9201"C62- Project Valuation: $3900.00 Blg. 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: 01/10 Visa ■ MasterCard 0 Discover 0 American Express d