07100206 CTTx OF CUPERTINO y � n ' ' T
� BUfLD1T�IG DIVISION r E111V111 ���� ��� ������ °
. .. » >..:..... . .. _
PERMIT NQ
BUILD �� n ��� ss �TEVENS CREEK BLVD # 10 6 TBD — T J BE DETERMINED 0 710 0 2 0 6 .
PEItL�T ISSUE DATE
.�fER'S NAME:
PROMETHEUS REAL ESTATE GROUP 10/30/2007
SANTTARY NO. CONTROL NO.
PHONE:
BUtLDING PERMIT INFO
ARCHI7ECT/ENGiNEER: BLDG ELECT PLUMB MECH
� � 0 0
i p o LICENSED CONT'RACTOR'S DECLARAT[ON JO�] DeSCI7ptlOil
'� F., I hcrcby afGrm �hat I am licensed unckr provisions a( Chap�cr 9(commenc�eL
' wi�hSection7000)ofDivision3ofihcBusinessandProfcssionsCode.andmY��� REMODEL KITCHEN/BATH�W/D RETROFIT�DUCTLESS SPLIT
��? Licen�scClass ��.# SYS HVA� RETROFIT� NON-STRUCTURAL
; F, p Datc Conuactor
� ARCHITECI'S DECLARATION
i a Q f undcrstand my plans shali 6c uud as public records
)yU
° a y Licensed Prufcssional
� � a OWNER-BUILDER DECLARATION
j a� 1 hcrcby alTirm th�t 1 am excmp� Crom ihc Conuactor's Liccnsc Law Cor �hc
. p O following rcason. (Section 7U31.5, Busincss and Profcssiunt Codc: Any city or rnunty
�^� which rcquires a pertnit to rnnswc4 alicr. improvc. dcmulixh, or rerytir any suucture
prior to i�s istuancc, alsu rcquires thc applicant for such permit w filc a signcd sulcmcnt �; Ft. Floor Area Valuation
� z � that he is liccnscJ pursuant to thc provisions of thc Conuactor's Liccnsc Law (Chaptcr 9 � $ 3 9 0 0
� t— �(commencing wiih Section 70W) oC Division 3 oC �hc Business and Profcuions Cadc) or
L�.. ihat he is exempt thcrctrom md ihe basis for �Ae allegcd exemption. My violuian ot
Secdon 7031.5 by arry applicant for a pennit su6jects ihe applicant to a civil penalry a[ 3 6 9 010 2 6 A�� Number Oeeupaney Type
not more than five hundred dollars (5500). •
❑ I, ss owner of tl�e property, or my cmploycu wit4 wages az their solc compenuuon.
wi:l do 1hc woik, and ihe �L�:circt is notintended o� offeced [o� sale (Sec.70A4. Busi�sa Required Inspections
and Professions Code: The CnnuacWr's Licenu Law doct na app�Y �u so u"'nec °�
propeny who builds or improves thereon, and who does such worlc himultar Woup,d 6is
own employccs, providcd tAat such improvements are not intended ar oQered Cor sal� I[,
howevcr, the building or improvement is sotd within o� year oC compledon, the owner-
builder will have the burden o( proving that he did rot build or improvc for po�pose a�
salcJ.
❑ l, as awner o! the property, am ezctusively convaaing wiU� licensed rnouactors to
construct the project (Sec. 7044. Busineu and ProC�ssons Cade:) The Conuaet�s Li-
cense Caw docs not apply to an ownu o( propeny w6o builds or improvrs �dneon. and ,
who convacts tor such projec�s with a contractor(s) licensed parsmnt to t4e Conu�acwfs
l.iccnse Law.
` am exempt undu Sec . B dc P C for this �euon
_«ner Da�e _ .
WORKERS COMPENSAT70N DECLARATION
I hereby �tm under penalty of perjury ane ot the falbwing declaruian�
❑ I hs.�e and will maintain a Certi6cate of Consent to selFinsurc Cor Workcrs Canpen-
sation, as providcd for by Section 3700 of the Labor Code, for the pcdormance of �he
work for whieh Ihis pertnit is issued.
❑ I havc and will maintain Workers Componsation Insunnce, as �equired by Scction ,
3700 0( �he Labor Code, for the pedortnance oF the wodc for v+6ich �his pecmit is issued
My Worker's Compensation lnsurance cartier and Poliey number arc:
Carrier. Policy No.:
CERTIF[CATE OF EXEMP170N FROM WORKERS'
COMPENSATION [NSURANCE
(Chis scction necd not bc campletcJ if the pecmit is for onc hundred dollus (S I00) ,
orlcss.)
I ceni(y that in thc performancc of thc work for whicd ihis pertnit is istucd. I shall not
employ any person in any mmncr so as to bccomc subject to the Workcrs' Compensauon
Laws oC Calitomia. Datc
Applicant
NOTICE TO APPLICANT: If, aftcr making U�is Ccrtifica�c of Excmptian, you shouhl
become subjcct to lhc WorkePs Compcnsadon provisions of thc Labor Codc, yau must
� z forthwi�h comply wi�h such provisians or this pccmit shall bc dccmcd revokcd.
z O CONSTRUCTION LENDING AGENCY
F r r�-� I hcfchy a[linn ihat t►kre is a coRCwction Icnding agcnry Cor thc perCormar�cc uC -
(Y, � �hC wurk for which this pertnit is issued (Sec. 3097. Civ. C.) ,
W Q Lcndcr's Namc
L,cnder's Address
U � 1 certi(Y ihat I have rcad this application and staic ihat thc above infwmatiuo is
�� cortect. 1 agree to comply with all ciry and county ordinance: and sute laws rclaung w
� J buildiag conswction, and hcrcby authori�e rcprescntativcs of �his city to cn�cr u�a �hc
W abovc-mcntioned property (or inspccuon purposes.
�' (Wc) agrce to save, indcmnify and kccp hartn)ess the Ciry o[ Cupcnino against
*y � liabiliuu, judgmcnts, costs and expenscs which may in any way accrue agains� said Ciry
U z in consequence oC thc granting of Ihis permit. DaLe
�-+ APPLICANT UNDERSTANDS AND WILL COMPl.Y W17H ALL NON-POIP(f Issued by;
SOURCE REGULATIONS.
Re-roofs
Signawrc of ApplicanUContractor ���
HAZARDOUS MATERIALS D[SCLOSURE Type of R.00f
Will thc applicant or futurc building occupant store or handle hmardous ma�rial
kfined by the Cupenino Municipal Codc. Chaptcr 9.12, and t6e Hcahh and SaCcty
�xlc. Scction 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs O No .
Will ihc applicant or Cuwrc building accupant usc equipment ar dcviccs which
If a roof is installed without first obtaining an inspection, I agree to remove
cmit harardous air contaminan�s az Jcfincd by �he Bay Area Air Quality Managcment alt new n.aterials for inspection.
Dis�rict?
� yas ❑ Nu
1 havc rcaci the ha�ardcws ma�crials rcyuircmcn�s undcrChapicr 695 of thc Califor-
nia Hcal�h & Safcry Codc, Scctions 25505, 25533 arul 75534. I undcrsiand that i[�he boildNE
does not curtently have a tenant, ihat i� is my responsihilily to notify �he occupant of ifre
rcyuircmcn�s which mus� bc mel prior lo issuancc o( a Ccnificaic of OccupancY- Signature of Applicant Date
Atl roof coverings to be Class "B" or better
Owncr or authori•r.cd agcnt �'� �
CITY OF CUPERTINO
7 ITEMS OF 35 PERMI7' RECEIPT OPER.ATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Bl}:: Lot:
APN ......... 36��01026.30
DATE ISSUED.......: 10�'30/2007
RECEIPT #.........: BS(100003124
REFERENCE ID # ...: 07:_00206
SITE ADDRESS .....: 20;�80 STEVENS CREEK BLVD #106
SUBDIVISION .......
CITY .............. CU]'ERTINO
IMPACT AREA .......
OWNER ............: PR()METHEUS REAL ESTATE GROUP
ADDRESS ..........: 19()0 S NORFOLK ST #150
CITY/STATE/ZIP ...: SAId MATEO, CA 94403
RECEIVED FROM ....: OR:=ON FINCL SVCS
CONTRACTOR .......: TB]) - TO BE DETERMINED LIC # 00096
COMPANY ..........: TB]) - TO BE DETERMINED
ADDRESS ...........
CITY/STATE/ZIP ...: ,
TELEPHONE .........
FEE ID UNIT QUANTITY ��MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -�--------- ---------- ---------- ----------
BENERGY PERMIT FEE 104.76 50.28 0.00 50.28 0.00
BPERMFEE VALUATION 3,900.00 104.76 0.00 104.76 0.00
BREMACOVER NO UNITS 1.00 17.82 0.00 17.82 0.00
BSEISMICRE VALUATION 3,900.00 0.50 0.00 0.50 0.00
EPERMITFEE FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
MPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
PPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 295.73 0.00 295.73 0.00
C��"11��a��
CITY OF C'UPERTINO
CUPE TI�10 PE�IT APPL][CATION FORM
�
APN # Date:
� 6Q. � � - O 2 �; � � �� p --a !7
Building Address: Mailing Address (if different from building address):
;l C�_38'o 5��•,r�s Cr1<_ [31�. a �`fl?G�
Owner's Name: Phone #:
P�-��ne�n �s� C'� � e��e, �� � S 3-- 7/ o v
Contractor: � License #:
C>r`,un � � ��.
✓ � y�7 t'
Contact: PhoneC ?� Z— k`{� Cupertino Business License#:
S-�e�� w�n �� F����c�) � ��� - io
Building Permit Info: w/D re7Yaf:t k-►k��n �(� � ��roJ-� � 0�•� sPl;t s�.r U,.,.,
}.��6 A, c re-�w f', �_— r� c�/l S'-�v�. vtu�Q.( �
Bldg C�YY Elect �� F'lumb 0� Mech C�'
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: �-' Occupancy Group:
,� vQ C�� Q� (
'?'ype of Co�ruction: Please check this box if th�e project is a
_ � second-stor addition:
Project Size: Standard C�' Large ❑ Maj or ❑
Quanti Fee ID F'ee Descri tion Fee Grou
BAPPLOTHER (�ther Ap liances MECHANICAL
BBOILERI Bo �ler <= 100,000 Btu MECHANICAL
BBOILER2 Boiler > 100K to SOOK Btu MECHANICAL
BBOILER3 Boil�r > SOOK to 1M Btu MECHAl�TICAL
BBOILER4 Boiler > 1M to 1.75 M Btu MECHANICAL
BBOILERS Boiler > 1.75M Btu MECHANICAL
BCONSTAX ��onstruction Tax BUILDING
BCONSTAX In�i/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Co:lst� — Resi/Mobile BUILDING
BELEC 1000 El �c 600V <= l 000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
' BENERGY Energy BUILDING
BENERGYADD �;nergy Add Multi BUILDING
� BINVESTIGA Investigation fee BUILDING
1 of 3
� CITY OF CrUPERTINO
CUPEI�TINt3 PERMIT APPL:[CATION FORM
Quanti Fee ID Fee Descri tion Fee Grou
BREMSIGNAD Rmcil Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR The atrical Lighting Fix ELECTRICAL
BREMVENFAN Ve�it Fan Sin le Duct MECHANICAL
BREMVENSYS Vf�ntilation S stems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Sei smic Commercial BUILDING
BSEISMICRE �ieismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Tem orar Power ELECTRICAL
BTEMPPERM Tem orar Bld Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC �tusiness License BUILDING
ELECTRIC ]:lectrical sq foot ELECTRICAL
EPERMITFEE ElE c Permit Issuance ELECTRICAL
MPERMFEE M echanical sq. foot MECHANICAL
MPERMITFEE Mer.h Permit Issuance MECHANICAL
PPERMITFEE Plu�nbin Permit�Issue PLUMBING
PPLBG Pli�mbin Fee sq foot PLITMBING
PLLONGRNGC Plannin LR Comme/ Multi-Fam PLANNING
PLLONGRNGR Plannin Lon Ran e Residential PLANNING
3 of 3
1 U�iUU 'focre Avenue
_ �'`� � Cupeitino CA 95014
i �:_ ,=.- " _
Telephone (408) 777-32�8
� , inC � iAI^ Fax(408)777-;;33
UrCI� ��vv
Buildi.n De artment
i JOB t�DDRESS 20380 STEVENS CREEK BLVD � PERMIT #
, CUPERTINO, CA 9501 4 AQ'� �� O� � QO� ��
OWNER�S NAME:PROMETHEUS REAL ESTA7'E GROUP PHONE #( 91 6) 7 8 9- 8 4 8 4
� GENERAL CONTRACTORsTEVE WHITESIL�ES FAX #( 91 6) 789-1 051
I am not using any subcontractors:
S� ��'� Date
Please check a licable subcontractors and com lete th.e followin information:
!- SUBCOl��'RACTOR BUSIrdESS NAME BUSINESS: LICENSE #
� Cabinets & Millwork
Cement Finishing
Elec
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
x Heating SAN JOSE AIR ( 1 408 ) 286-ZQ47
� Lnsulation
j Landscaping
� Lathing
� Masonry
Ornamental Sheet Metal
! Painting / Wallpaper
I Paving
� Plastering �
� Plumbing
1 Roofing
! Septic Tank
' Sheet Metal
� Sheet Rock
� T
� z8 �
Owner/ Contractor Signat�c�re Date