15010040CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19499 STEVENS CREEK BLVD
CONTRACTOR: DEVCON
PERMIT NO: 15010040
CONSTRUCTION INC
OIVNER'S NAME: MAIN STREET CUPERTINO AGGREGATOR LL
690 GIBRALTAR DR
DATE ISSUED: 01/07(2015
ER'S PHONE: 4087251955
MILPITAS, CA 95035
PHONE NO: (408)942-8200LICEN
E D CONTRACTOR'S D C ARATiON
TINSTALLATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
3
OF TEMP TRAILER FOR OFFICE
License Class Lic. 4 3 el -q +
BUILDING
Contractor �� �ver5�r�+G fii9n Date 1 --7 T i S
528 SQ FT
I hereby affirm that I am licensed under the provisions ofChapter9
(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 hvo 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 Arca:
Valuation: $5000
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: 31620085.19499
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
W RK IS NOT STARTED
PERMIKFM
correct. I agree to comply with all city and county ordinances and state lacus relating
WITHIPERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this eity to enter
upon the above mentioned property for inspection purposes. (Wc) agree to save
ISO DAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Issued by:Date:
with all non -point source regulations ger Vie Cupertino Municipal Code, Section
9.18.
A
R RDFS:
c a ntr - ����ate/
All roofs shall be inspected prior to any roofing material being installed, if a roof is
installed without first obtaiuing an inspection, i agree to remove all new materials for
inspection.
❑ OIVNER-DUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
J
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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 & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sce.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilcalth & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby afrrnr under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.I2 and the
declarations:
Health & Safety Code, Section 25532(x) 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 Arca Air Quality Management District I
performance of the work for which this permit is issued,
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Ilcalth & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
r nt. ate:
permit is issued,
s er rrt�att{ _
I certify that in Ilse 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
1 hereby afftmt 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 pemit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT ANT CERTIFICATION
Lender's Address
I certify that I have read this application and stare that the above information is
correct. 1 agree to comply with all city and county ordinances and stale 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,
ARCiIITF.CT'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 • buildinaCakupert! no.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS1 4 GGl1 fel p„ ayL s yam. �_
APN M 2U b8S, �-
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CONTRACTOR NAME Cp ��
LICENSE NUMBER.� u ] 1
LICENSE TYPE
BUS, LIC N
COMPANY NAME �� �dyt �{ p��
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FAX
STREETADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECTIENGINEER NAME
LICENSE NUMBER
BUS- LIC H
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
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DESCRIPTION OF WORK
fff f/ Cr x
I
EXISTING USE
PROPOSED USE CONSTR.
TYPE
I # STORIES
USE TYPE OCC.
SQ.PT.
VALUATION (5)
EXISTG
AREA
NEW FLOOR
APPA
DEMO
AREA
TOTAL
NET AREA
BATHROOM
RB40DELAREA
KITCHEN
REMODELARFA
OTHER
REMODELAREA
PORCH AREA
DECK AREA
TOTALDECKMORCHAItiA
GARAGE ARTA: DETACH
ATTACH
A DWELI-ING UNT17S.
IS A SECOND UNIT YES
BEING ADDED? NO
SECOND STORY []YES
ADDITION? ONO
PRE -APPLICATION OYES IF YES, PROVIDE COPY OF
PLANNING APPL # ❑ NO PLANNING APPROVAL LEITER
1S THE BLDG AN ❑ YES
MCHLER HOST i? ❑ NO
RECEWED
TOTAL VALUATION:
Lr' /s7/� J
By my signature below, I certify to each of the Following: 1 am the property owner or authorized agent to ac on roperty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is t I agree to comply with all applicable local
ordinances and state laws relating to building const 1 orize representatives of Cupertino to enter the above -identified property for inspection purposes.
SignalureofApplicant/Agent: Date: %Z 2
SUPPLEMENTAL INFORMATION REQUIRED
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if any Hazardous Materials are being used as part of this project.
_ Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Pennit application.
PLAN CHECK TYPE
ROUTING SLIP
OVER-THE-COUNTER
❑ BxPREss
13 STANDARD
❑ LARGE
❑ MAJOR
BUILDING PLAN REVIEW
❑ PLANNING PLANRrvIEw
❑ PUBLIC WORKS
FIRE Derr
❑ srANrrARY SE1.vER DISTRICT
❑ ENVIRONAfENTALIIEALTH
B1dgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR -- BUILDING DIVISION
NOTE. This estimate does not include fees due to other Deparhnents (La Planning, Public Works, Fire, Sanitary Server District, School
District. etc.). These fees are based on the nrelinthtary information available and are only an estimate. Contact the Dent for addrt'l into.
FEE ITEMS (Eee Resolution 11-053 E . 7f? LI 3)
ADDRESS: 19499 SCB
DATE: 01/07/2015
REVIEWED BY: Mendez
Tech, Permit Fee:plumb,
APN:
BP#: ��j b
"VALUATION: 1$5,000
*PERMRT TYPE: Building Permit
PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY
USE: Commercial Building
--PENTAMATION
PERMIT TYPE: 1 GENCOMA
WORK
INSTALLATION OF TEMP TRAILER FOR OFFICE BUILDING 528 SQ FT
SCOPE
Suppl. Insp. Fee:Q Reg. O OT0,0 his
NOTE. This estimate does not include fees due to other Deparhnents (La Planning, Public Works, Fire, Sanitary Server District, School
District. etc.). These fees are based on the nrelinthtary information available and are only an estimate. Contact the Dent for addrt'l into.
FEE ITEMS (Eee Resolution 11-053 E . 7f? LI 3)
hfach. I'lryr Check
Plumb. Plan Clre e°
Vec•, Pkrn Check
Tech, Permit Fee:plumb,
Perrnir Pee
Dec, Penpli! Fee.:
Ofher Jvfeh. Asp.ET-1-
0(her Phimb hasp.El-�--
E1--t-
Other Elec. In," .
Alech. Imp. Fre:
l'honb, Insp. Fee'.
Dec. hup. Fee:
NOTE. This estimate does not include fees due to other Deparhnents (La Planning, Public Works, Fire, Sanitary Server District, School
District. etc.). These fees are based on the nrelinthtary information available and are only an estimate. Contact the Dent for addrt'l into.
FEE ITEMS (Eee Resolution 11-053 E . 7f? LI 3)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
## Temporary Structures
$430.00 ITEMPSTR
Suppl. PC Fee: Q Reg. O OTI
0.0
1 hrs
$0.00
PME PIan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. O OT0,0 his
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax.
Adniirustradw Fee:
E)
Work Without Permit? ® Yes Q No
$0.00
Advanced PIanning Fee:
$0.00
Select a Non -Residential G
Building or Structure 0
I
Traiwl Dociawntation Fees:
Strong Motion Fee: IBSEISMICO
$1.40
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$2.40
$430.00 TOTAL FEE:
$432.40
Revised: 01/06/2015