15010091 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20450 STEVENS CREEK BLVD CONTRACTOR:SC BUILDERS INC PERMIT NO: 15010091
OWNER'S NAME: CUPERTINO CITY CENTER BUILDINGS 910 THOMPSON PL DATE ISSUED:01/15/2015
OWNER'S PHONE: 6502805188 SUNNYVALE,CA 94085 PHONE NO:(408)328-0688
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E]
6TH FLOOR; SE WING; ADDITION OF(2)DOORS
License Class � Lic.# � ['
ContractoryC &10?pS> Date "�J ' S-
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$30000
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:36901027.00 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 1110 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 1110 DAYS 77AST CALLED INSPECTION.
indemnify and ke harmless t City of Cupertino against liabilities,judgments,
costs,and expe which ma a rue against said City in consequence of the �! C�
granting of thi nit. A ly,the applicant understands and will comply Issued by: Date: J
with all non- . ource t 1 er the Cupertino Municipal Code,Section
9.18. _
1� , RE-ROOFS:
Signature Date 1 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
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)
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 l store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equ' ment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the B r0Airality Management District I
performance of the work for which this permit is issued. will maintain compliance with the rtipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code, d 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date
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,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 must 1 hereby affimt 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
indemnity 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
CONSTRUCTION PERMIT APPLICATION ot`
12 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 0
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPFRTtNO
(408)777-3228• FAX (408)777-3333•buildinq(LDcupertino.org
1�)
❑NEW CONSTRUCTION ❑ ADDITION LTER-ATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 15-0 Ve /
vele- 6��` 7 APN# O � '—
OWNERNAME PHONE E-MAIL
STREET ADDRESS ^ CITY, STATE,ZIP FAX
CONTACT NAME �'T , PHONE-m 2op ,,n4 E-MAIL �% e)D GA�P4-COI
STREET ADDRESS f y�e I _ ,/\ CITY,STATE, IP_ __1�,, "�1{A (1 6 r FAX
❑OWNER ❑ OWNER-BUILDER 'C❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECTr ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME J 1 OCIGa� LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NA 'C C E-MAIL FAX
STREET ADDRESSC " v Cn CITY,STATE,ZIP /•Ve• AV PH0NEf&-7
ARCHITECT/ENGINEE NAGE 1 +� LICENSE NUMBER BUS.LIC#
1Q �
K N
COMPANY NAME E-MAIL FAX
STREET ADDRESS +M CITY,STATE,ZIP r /+� PHONE
DESCRIPTION OF WORK M61 OF +r•_ o "boxi5 Q N I ",/ _ S V4
46-VIP
0 6' r g- � 15EXISTINGUSE PROPOSED USE CONSTR.TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
O ATTACH
#DWELLING UMTS: IS A SECOND UNIT ❑YES SECOND STORY OYES
BEING ADDED? ❑NO ADDITION? ONO
PRE-APPLICATION [:]YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VVAALU_AT;ON:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? NO K.
By my signature below,I certify to each of the f g: 1, 2, �
ner or authorized agent to act on the property owner's behalf. I have read this
application and the information I e pr6vl orrect. ayscription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relati buil nstru i n. la pr entatives of Cupertino to enter the above;identi�gdproper for inspection purposes.
Signature of Applicant/Agent: Date: ff// V �5
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ovER-THEcoUNTER BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑, EXPRESS ❑ PLANNING PLAN REVIEW"
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑,LARGE FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal Of Building Permit application. ❑ MAJOR El SANITARY SEWER DISTRICT -
❑ ENVIRONMENTAL HEALTH:
BldgApp 2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 20450 scb DATE: 01/15/2015 REVIEWED BY: Mendez
APN: BP#: 1_50&)o�? 'VALUATION: 1$30,000
`PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial BuildingL PENTAMATION 1 GENCOM
USE: PERMIT TYPE:
WORK 6th floor se wing; addition of 2 doors
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 ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Et'. 7,7.'13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? Q Yes (j) No $0.00 1 hours Plan Check, Hourly
Suppl. PC Fee: (j) Reg. Q OT0.0 hrs $0.00 $143.00 1STPLNCK
PME Plan Check: $0.00
Permit Fee: Hourly Only? 0 Yes Q No $0.00
Suppl. Insp. Fee:Q Reg. Q OT0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
0
Work Without Permit? 0 Yes (j) No $0.00 G
Advanced Planning Fee: $0.00 Select a Non-Residential G
Building or Structure 0
i
Strom Motion Fee: 1BSEISMICO $8.40 F-3-T-1 hrs Inspections
Bldg Stds Commission Fee: 1BCBSC $2.00 $429.00 ISTINSP Inspection, Hourly
SUBTOTALS: 1 $10.401 $572.00 TOTAL FEE: 1 $582.40
Revised: 01/06/2015