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15060062CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19638 STEVENS CREEK BLVD CONTRACT( PERMIT NO: 15060062 OWNER'S NAME: EVERSHINE VI, LP DATE ISSUED: 06/09/2015 01,R'S PHONE: 4083431088 PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL H&R BLOCK - T.I. TO REPLACE 8 (E) INTERIOR License Class Lie. # U tea I DOORSMARDWARE & RELOCATE 1 (E) DOOR �D Contractor x �JT tom 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 Sq. Ft Floor Area: Valuation: $7000 performance of the work for which this permit is issued. 1 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 APN Number: 36906012.19638 Occupancy Type: -permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save S ALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of thegranting of this permit. Addition y, thealicant understands and will comply4kFROMLA Date: with,all source regulations per the pertino Municipal Code, S 9.1�. \ a' " S RE -ROOFS: Signa Da 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. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain complian a wit a Cuperti N nicipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sectio s 25 5533 and 25534. Section 3700 of the Labor Code, for the performance of the work for which this JC Owner or authorized age. Date: 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9 18. Signature Date CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - build ing(a)_cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS l APN # - N OWNERN J PHONE �LJ E-MAIL STREET ADDRESS CrrY, STAT ZIP FAX CONTACT NAME PH STREET ADDRESSl CITY, STATE ZIP �-7"j FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CO RACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # O�ANY A , E, hf eYi �'�`� �� O` G �� • tel/ W t. STREET ADDRESS CITY, STATE, ZIP PHONE ARCHTTECTIENGINEERNAME LICENSEI Ur R BUS. LIC# COMPANY NAME E -MATT. FAX SIR,TDDRESSC L+ TY, STATE, ZIP PHONE _1952 DESCRIPTION OF WORK �,–� _ - r �, w oG EXISTING USE PROPOSEDUSE CONE U SGJy #STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXESTG AREA J q I NEW FLOOR AREA DEMO AREA TOTAL NET AREA BATHROOM KIT HEN OTHER REMODEL AREA REMODELAREA REMODELAREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: []DETACH I ❑ ATTACH I # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? []NO - PRE -APPLICATION [IYES IF YES, PROVIDE COPY OF IS THE BLDG AN El.ARE •- -I JOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER DOME? By my signature below, I rtify to each of the llowing: I am the p erty owner authorized o act the pe er's behalf. I have read this application and the info ation I have provided ' correct ave r e Description Mork and verify Is ac te. I agree to y with all applicable local ordinances and state laws relating to• uildin onstructio I a raze r resentatives f Cupertino to ter above -identified property for inspection purposes. �qSignature of Applicant/Agent: SUPPLEME AL E�ZORMATION REQUIRED PLAN CHECK TYPE ;:ROUTING SLIP ❑ BUILDINGPLANREVIEw New SFD or Multifamily dwellings: Apply for demolition permit forQ existing building(s). Demolition permit is required prior to issuance of building OVER -THE COUNTTIt ; permit for new building. ❑ EXPRESS ❑ :PLANNING PLAN Rt VIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ —P"UBLIC WORKS . form if any Hazardous Materials are being used as part of this project. LARGE ❑ 'PIREDEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to❑ MAJOR ❑,',SANITARY SEWER DISTRICT submittal of Building Permit application. - ❑-�' ENVIRONMENTAL-IIEALTD. `. BldgApp_201 Ldoc revised 06/21/11 IYA CITY OF CUPERTINO II FEE ESTIMATOR - BUILDING DIVISION v ADDRESS: 19638 STEVENS CREEK BLVD DATE: 06/09/2015 REVIEWED BY: MELISSA APN: 369 06 012 BP#: Q&,,_? *VALUATION: 1$7,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: hrs PENTAMATION 1GENCOM PERMIT TYPE: WORK H&R BLOCK - T.I. TO REPLACE 8 E INTERIOR DOORS/HARDWARE & RELOCATE 1 E DOOR SCOPE NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc-). These fees are haled an tl:e nrelintinary information availahle and ore nnly an estimate_ rantart the sant fnr addn'l ;"fn_ FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 hours $143.00 Plan Check, Hourly ISTPLNCK Suppl. PC Fee: Q Reg. 0 OT0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Supp/. Insp. Fee:Q Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consfructlon Tax. tdrninislrative Tee: 0 0 Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee. $0.00 Select a Non -Residential Building or Structure 0 i 7i �rnE'l L)ocarrn.erztati�rn Tees: Strong Motion Fee: IBSEISMICO $1.96 3.0 hrs $429.00 Inspections ISTINSP Inspection, Hourly Bldg Stds Commission .Fee: IBCBSC $1.00 SUBTOTALS:;:: $2.96 $572.00 TOTAL FEE $574.96 Revised: 05/07/2015