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09070136 CITY OF CUPERTINO BUILDING DIVISION PERMITI�QI�N� BUILDING ADDRESS: PERMIT NO. 10212 N DE ANZA BLVD BENCHMAaK CN OWNER'S NAME: PERMIT ISSUE DATE . E: S A iNCONTROL NO. (650) 938-1802 ARC Cr/ENGI BUILDING PERMIT INFO n\ n BLDG ELECT PLUMB MECH '0 p LICENSED CONTRACTORS DECLARATION Job Description m I hereby affirm that I am licensed under provisions of Chapter 9(commencing cwith Section 7000)of Division 3 of the Business and Professions Code,a my license is y in full force and effect UNDERGR JUND TEMP POWER POLE Z License ass Lic. Date Contractor ARCHITECPS DECI err� I understand my plans shall be used as public records a. U L p y Licensed Professional n 0 OWNER-BUILDER DECLARATION Cnl I hereby affirm that 1 am exempt from the Contractor's License Law for the 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county 43� which requires a permit to construct.alter,improve,demolish,or repair any structure Z prior to its issuance,also requires the applicant for such permit to file a signed statement _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation 9t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 5 0 O O 0 y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars($500). 31626083 . 00 ❑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 Re uired Ins ections and Professions Code:The Contractor's License Law does not apply to an owner of q p property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.if, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License law. ❑1 am exempt under Sec .B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,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 required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Wo�esC tt a aI:as I t ,No.. �JFROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars MOD) or less.) I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY (~i►�-. I hereby affirm that there is a construction lending agency for the performance of (Y> the work for which this permit is issued(Sec.3097,Civ.C.) WL1.Q Lender's Name Lender's Address V 0 1 certify that I have read this application and stale that the above information is LL►" cormcL I agree to comply with all city and county ordinances and state laws relating to 0 V building construction.and hereby authorize representatives of this city to enter upon the U above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against rF-t lA liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. y Date , S APPLICANT UNDERSTANDS AND WI WITH ALL NO -POINT Issued b : SOURCE REGU TIONS. �b Re-roofs Signature ofApplican tractor Date HAZARDOUS MATERIALS DISCLOSURE Type of R sof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Cole,Section 25532(a)? All roofs:;hall be inspected prior to any roofing material being installed. ❑Yes KNo Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes r®Nu 1 have mad the ha7mdous4tg1crials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections and 25534.1 understand that if the building does not currently have a tenant.that ism rsibility to notify the occupant of the requirements wh' must be et r n rtific or cu Signature DfApplicant Date Owner or tswh authorized nt O _ All roof coverings to be Class in"or better CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec : Twp: Rng: Sub: Blk : Lot : APN . . . . . . . . : 31626088 . 00 DATE ISSUED. . . . . . . : 07/17/2009 RECEIPT #. . . . . . . . . BSC00008216 REFERENCE ID # . . . : 09C70136 SITE ADDRESS . . . . . : 10212 N DE ANZA BLVD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : 10212 N DE ANZA LLC ADDRESS . . . . . . . . . . : 17C66 MELODY LN CITY/STATE/ZIP . . . : LO.c GATOS, CA 95033 RECEIVED FROM . . . . : BENCHMARK CONST CONTRACTOR . . . . . . . : BRIAN SMICK LIC # 30212 COMPANY . . . . . . . . . . : BENCHMARK CONSTRUCTION ADDRESS . . . . . . . . . . : 1045 LINDA VISTA AVE CITY/STATE/ZIP . . . : MOLNTAIN VIEW, CA 94043 TELEPHONE . . . . . . . . : (650) 938-1802 FEE ID UNIT QUANTITY FMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 750, 000 .00 30 . 00 0 .00 30 . 00 0 . 00 1BSEISMICO VALUATION 750, 000 .00 157 .50 0 .00 157 .50 0 . 00 IECT<200 UNITS 1 .00 42 . 00 0 . 00 42 . 00 0 . 00 1EPERMITFE 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 313 . 50 0 . 00 313 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 313 .50 #6315 --------------- TOTAL RECEIPT 313 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 402 TEMPORARY POWER 505 FINAL ELECTRICAL o9v-75�� CITY OF CUPERTINO TEMII POWER CUPEkTINO PERMIT APPIACATION FORM APN# S KC�, — a6-0 O s . O 0 Date: 7 1 1 7 0 Building Ads O is e: PhoN VO �0� r GS— 23�( A w 1� Contractt�rnA �' Phone#: (,SO a3%.IS o ), Fax#: (a5p g3tS — l SOS Contact: �E r ^ Phone : �S (LA 5 Contractor License#: Cupertino Business License#: 3 Job Description:Q jEMxjF—�— Mir> vnct� Residential El Commercial 'A Valuation(cost of project): 5U u�l Type of Constructio : /A Quantity Fee ID Fee Description Fee Group Permit Type 1 ERT>1 K Res. Temp Po)ver>I K E 1REAP14 Amps 1 ERT<200 Res. Temp Power<200 E Amps 1 ERT2001 K Res. Temp Power 200-IK E Amps / 1 EPERMITFE Electric Permit; Issuance E 1 ELCPLNCK Electric Plan Check E I 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICR Seismic Residential B 1 TRAVDOC Travel & Documentation B IFee Revised 01/07/09 Community Development 10300 Torre Avenue ' ;y Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 .,,UPEkTIN0 Building Department JOB ADDRESS: PERMIT # &?l 3 OWNER'S NAME: Scrc 1qa 2. PHONE # , 1%0;i, GENERAL CONTRACTOM:4 C V1 In A,q, S FAX # I am not using any subcontractors: l� Q i;mature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date