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14030076 CITY OF CUP ERTENO BUILDING IFIERMET BUILDING ADDRESS: 19089 STEVENS CREEK BLVD CONTRACTOR:ELK GROVE BUILDERS PERMIT NO: 14030076 INC OWNER'S NAME: UNITED POLARIS INC 9918 KENT ST STE 1 DATE ISSUED:05/29/2014 OWNER'S PHONE: 9188723223 ELK GROVE,CA 95624 PHONE NO:(916)685-1100 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL a License Class Lic. TENANT IMPROVEMENT(HIL.TI)(3200 SQ FT). /J � # 1 � �}y Contractor f d'e (}//��`8 V& r Date Ar-2? —/7 I hereby affirm that 1 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: 1 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:$100000 I hav 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:37507046.19080 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT]E 'IRES IIIF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating �IT)(�)� ��� ®�PERMIT�������� ®� to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAJ ILII(LAST CALLED I[I�1SP CT)( 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. Add iti the applicant understands and will comply Issued by: Date: �� with all non-point source ulations er the upertino Municipal Code,Section 9.18 RE-ROOFS: Signature Date y 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 1 hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Seetions 25505,25533,and 25534. I 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 1 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 compliance with the C •tino l nicipal ode,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safet 25505,2553 ,a 534. Section 3700 of the Labor Code,for the performance of the work for which this —�7 / permit is issued. Owner or authorized age 15. Date: I certify that in the performance of the work for which this permit is issued,l 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 I Lender's Address 1 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, 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 10 CONSTRUCTION PERMIT APPLICATION [[�� COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION V� 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 " �o (408)777-3228• FAX(408)777-3333^building aagupertino.orgCUPERTINO \ ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT tt PROJECT ADDRESS p(doge r APN# 3 y �r— - O OWNER-­­ ` I _ PHONE rJ E-MAIL (,�M a- �o — 2— 2-2- OA-Q- STREET ADDRESS ©� ^ �/� , CiT STATE,ZIP , FAX CONTACT NAME �/ V PH E-MAIL (:)NDS ITU 11- Z STREET ADDR)Ia Z VIC;F CITY,STATE,,r t74/2FAX 11OWNER El OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONPACTOR AGENT ❑ ARCHITECT 10/ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCH rECTIENGINEER 14,WE LICENSE NUMBER BUS.LIC# COMPANY N MT E-MAIL FAX STREET ADDRE CITY TA E, P PHON J o_ DESCRIPTION OF WORK ! 'p' � , 1 ,J 2- NW A-DA gr_ngenms /4W L d )N — c&- H A G L�oyz k . EXISTING USEPROPOSED USE CON TR TYPE #STORIES �Tllx� L — I/ _ USE TYPE OCC. SQ.FT. VALUATION(S) EXIST NEW Fl�OOR DEMO TOTAL AREA�Zoz AREA d AREA NET AREA F /I/I 3�no BATHROOM KITCHEN OTHER {Y f� REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ATTACH #DWELLING UMTS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? V0 ADDITION? ®NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECE ED BY: TOTAL VALUATION: PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO � 6� By my signature below,I certify to each of the followi : I am f property owner or authorized agent to act on the property owner's beha I have read this application and the information I have provided is c ect. lave ad th Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building c ;;t Hon I horize r resentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: 3 SUPPLEMENTAL INFORMATION REQUIRED rLax cxEcx TPPE u ' RotiTlNc silP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ oVER-THE-CO uNTER ❑ 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 ❑ STAN ❑.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 ❑ MAJOR ❑,SATITARY SEWER DISTRICT' submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BIdgApp_1011.doc revised 06/11111 CITY OF cCUP EII RANO FEE ESTIMATOR— IBUE LMNG DIIVIISIION ADDRESS: 1908V STEVENS CREEK BLVD DA'L'E: 03/12/2014 REVIEWED BY: MELISSA APN: 375 07 046 BP#: -76 *VALUATION: $100,000 rIPERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY PENTAMATION USE: Commercial Building PERMIT TYPE: 1 M "I-4 WORD HILTI -T.I. TO RECONFIGURE INTERIOR ADD 2 N ADA RESTROOMS IWE.P.'S SCOPE OCCUPANCY TYPE: TYPE OF I+LR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. (s.f. M (Tenant Improvements) II-B,111-BjV,V-B 3,200 $3,176.66 1MTIPLNCK $2,634.54 1MTIINSP TOTALS: 3,200 $3,176.66 $2,634.54 M EC]Hl,HOURLY ® Yes 0 No PLUMB,HOURLY Q Yes I ) No lELEC,HOURLY Q Yes Q No o ;', : , I. ( PL„irh. I'lcu,i(Yuci; Elec. f'lan('hrcic 1.;.•,;,. Fev 111,1111). Perr.il F e: 1lec. Pcnnir lee: )�r�,� ..'i'. :r. G, r• Inst, D I Ol/ter Flee.Insp. ;, '. r.c.,. f,,nul, lu,p. lF.' 1let.Insp. Fee 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 relimina information available and are onl an estimate. Contact the De t or addn'l info. ]FLEE ITEMS (Fee Resolution 11-053 E f 711,1132 FEE QTY/FEE 1l ISC ITEMS Plan Check Fee: $3,176.66 Select a Misc Bldg/Structure Suppl. PC Fee: D Reg. () OT Q,0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $2,634.54 Suppl. Insp. Feer Reg. Q OT Q Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 0 Work Without Permit? ® Yes (F) No $0.00 E) Advanced PlanninL Fee: $0.00 Select a Non-Residential -uc Building or Structure 0 r��;r.'r-1;,,111,, r'CC.S d Strong Motion Fee: IBSEISMICO $21.00 Select an Administrative Item Blda Stds Commission Fee: 1BCBSC 1 $4.00 SUBTOTALS: 11 $5,836.20 $0.00 TOTAL 1F1ElE.' $5,836.20 Revised: 01/1512014