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15120033CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15120033 10033 SAICH WAY CUPERTINO CA 95014 (326 32 041) (SILICONX CONSTRUCTION INC) SAN JOSE, CA 95131 OWNER'S NAME: (SAICH WAY STATION LLC) DATE ISSUED: / Tg OWNER'S PHONE: PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Clasc.,' ON#X A ` BLDG ELECT PLUMB Contractor ( S1c,RUCTION INC) Date _ _ _ MECH_ RESIDENTIAL COMMERCIAL 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. JOB DESCRIPTION: H&R BLOCK - INSTALL TEMPORARY TRAILER FOR SERVICE I hereby affirm under penalty of perjury one of the following two declarations: TO PUBLIC / EMPLOYEES FOR USE DURING CONSTRUCTION i. 'I have and will maintain a certificate of consent to self -insure for Worker's (678 SQ FT). , 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 Sq. Ft Floor Area: Valuation: $8000.00 this permit is issued. APPLICANT CERTIFICATION certify that I have read this application and state that the above information is correct. I agree to comply with all city and county APN Number: Occupancy Type: ordinances and state laws relating to building construction, and hereby 326 32 041 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 PERMIT EXPIRES IF WORK IS NOT STARTED expenses which may accrue against said City in consequence of the WITHIN 180 D RM[T ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal 180 D T CALLED INSPECTION. Code, See' n 9.18. Af / - sS by: -1 Sig t DateT4 Dater /6 OWNER -BUILDER D CLARATI RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for i. I, as owner of the property, or my employees with wages as their sole inspection. compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: 2. I, as owner of the property, am exclusively contracting with licensed Date: contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: r. 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the 2. I have and will maintain Worker's Compensation Insurance, as provided for California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will by Section 3700 of the Labor Code, for the performance of the work for which maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous this permit is issued. material. Additionally, should I use equipment or deviceswhich emit hazardous 3. I certify that in the performance of the work for which this permit is issued, I air contaminants as defined by the Bay Area Air Quality Management District I shall not employ any person in any manner so as to become subject to the will maintain compliance with t Cupertino Municipal Code, Chapter 9.12 and Worker's Compensation laws of California. If, after making this certificate of the Health & Safety` e, Section 25505, , an 534. 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 Owner or authorized a of be deemed revoked ., Date: t - s� z N T IN Y APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments, costs, and expenses which may accrue against said City in ARCHITECT'S DECLARATION consequence of the granting of this permit. Additionally, the applicant I understand my plans shall be used as public records: understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9,18. Licensed' Professional Signature Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTI NO (408) 777-3228 •FAX (408) 777-3333 • building(c�cupertino.org C S /J /} NEW CONSTRUCTION ❑ ADDITION LI ALTERATION/ Ti U REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS APN LA.� OWNERNAME .PHONE STREET ADDRESS CITY, STATE; ZIP FAX 2-(>S- I i Q N G,� d�z t 'etc A t) E 1 5 CONTACT NAME PHONE E-MAIL lfI �')oJy 7 att'�l�ils'i =�P ELS t6�91�5 .STREET ADDRESS 1S t U »4-t cv%.:b 1�.11 CITY, STATE, ZIP . S fxr,. 5 s S. 13 t FAX OWNER El OWNER-BUIIAER. a� OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME //''''���,, c� 1� t C,6*D- t f+ s-g4r, LICENSE NUMBER (� ®2 L f3 J 2— q 2— LICENSE TYPE BUS LIC # COMPANY NAME COMPANY --,jI t.ev�z ft t-. E-MAIL j+ x FAX STREET ADDRESS ) - CITY, &.TATE; ZIP , PH,9NE c� c ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC COMPANY NAME E-MAIL _ FAX STREET ADDRESS CITY, STATE,ZIP PHONE DESCRIPTION OF WORK. _. �...... L USE I TYPE 'I OCC. I SQ.FT. I VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM - ....KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA - ATTACH #DWELLING UNITS: IS ASECOND UNIT []YES SECONDSTORY U YES BEING ADDED? []NO ADDITION? []NO -PRE-APPLICATION F1 YES IF YES, PROVIDE COPY OF IS THE BLDG AN [j YES rRECI~;IV,ED x', TOT V UATION: PLANNINGAPPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read application and the information I have provided is correct. Lhave read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. /I'authorize representatives of Cupertino to enter the abo e�-nide tified property for inspection purposes. Signature ofApplicant/Agent: � t e � Date: � "1 �� BldgApp_201I.doc revised 06121111 CITY OF CUPERTINO FFF F.CTTM A TOP T RITII DING DIVISION w ADDRESS: 10033 SAICH WAY DATE: 12,/04/2015 REVIEWED BY: MELISSA FEE ITEMS Fee Resolution 11-053 E . 711113 APN: 326 32 041 BP#: *VALUATION: ls8,000 *'PERMIT TYPE: Building Permit $0.00 =PLANCHECKTYPE: Alteration /Addition/ Repair PRIMARY Commercial Building [Civil / Religious activities 0 Yes (j)No PENTAMATION 1 GENCOM PERMIT TYPE: USE: $0.00 PME Plan Check: in BQ Zone? WORK H&R BLOCK- INSTALL TEMPORARY TRAILER FOR SERVICE TO PUBLIC/ EMPLOYEES Permit Fee: $0.00 Suppl. Insp. Fee:( Reg. 0OT SCOPE hrs $0.00 l�L.=,. ;�� It i_a;�<trli: � � 1>.,tt.l). I'._itZ hl2 c'.: � •,t.°, i'ta � i;:`it`;?� 14 ch, lle ,3., f 010: `gni rA? --�< fjrt 'azt .� f=%`: -v.£. 1"'C'f P ,Y Fee: Ll �_ 3,r,v :brut i Ir"Meth.Lz'3 (.tYb,3 x<3t.E3 insp. Fee: ATn'rJ . Tlria ,tnov-hest hHi-1"do feo.c due to other Denartments (i.e. Planninz, Public Works, Fire, Sanitary Sewer District, School District, etc.. These fees are based on the preliminarV information available ana are omV an esumaze. uwncuce trie'"Upt jul uuu.c t .rtu. FEE ITEMS Fee Resolution 11-053 E . 711113 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # $430.0 elmporar3Strucre I TEMPSTR Suppl. PC Fee: Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:( Reg. 0OT Q • Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.Q0 Construction Tax: IBCONSTAXC $0.00 _. 'S No Work Without Permit? 0 Yes � $0.00 Advanced Planning Fee: $O.QO' Select a Non -Residential Building or Structure ybfp'3'ea #)%L;1tPlte'itbt.$£iori z`f'-es. Strong Motion Fee: IBSEISMICO $2.24 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 BT AL $3.24 $430.00' TUTAL FEE ; $433.24 (xrivll.ru. Lv�vuLY+.