13090079 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19420 HOMESTEAD RD CONTRACTOR:NCM DEMOLITION& PERMIT NO: 13090079
REMEDIATION LP
OWNER'S NAME: CAMPUS HOLDINGS INC 404 BERRY ST DATE ISSUED:09/11/2013
OWNER'S PHONE: 4087834613 BREA,CA 92821 PHONE NO:(714)672-3500
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL L1 COMMERCIAL
License Class 1 iyf Lic.# )4 6gs _ INTERIOR DEMO TO PREPARE FOR FUTURE BUILDING
AM !/ em f���`ky) om,4 ff�"M,v �� DEMO
Contractor (23,618 S.F)
I hereby affirm that I am licensed under the provisions of 6apteilY
(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:$50000
n 1 have and will maintain Worker's Compensation Insurance,as provided for by
�r I Section 3700 of the Labor Code,for the performance of the work for which this
APN Number:31607044.19420 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 D 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 180 D O 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 Z
granting of this permit. Additionally,the applicant understands and will comply I ate:
94"
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. G/
// i�� RE-ROOFS:
Signature Date 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
I hereby affirm that l 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
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. 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(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 Area 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 Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date: ��13 fiZ
I certify that in the performance of the work for which this permit is issued,I shall 61/
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 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
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 19420 HOMESTEAD RD DATE: 08/07/2013 REVIEWED BY: MELISSA
AIN: 316 07 044 , j R y Z0 I BP#: 6 -VALUATION: 1$50,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION 1TIPREP
USE: PERMIT TYPE:
WORK INTERIOR DEMO TO PREPARE FOR BUILDING DEMO (23,618 S.F.
SCOPE
deJC+. 1'i.ri7(.i!'E:r,'- :"!_lire).t`',131 f.,Ji BE:J" l>lE'C.P,cr%:
t
(lei;P.r':�/F;::i, i�i.�! (Fr;�.'.'.j�,�,r,,•a:LiiS�'7, r�i.<i'?'f.,.,.17"sLi
PhT mb../i?,ij7. Fee; > ee.
NOTE:This estin:ate does not include fees due to other Departinents(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the preliminar information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053Eff. 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1� # Tenant Improvement Prep
Suppl. PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 $405.00 1TIPREP
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:) Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
/PME Permit Fee: $0.00
t 0
Work Without Permit? 0 Yes ) No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential G
Building or Structure 0
Strong Motion Fee: 1BSEISMICo $10.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $2.00
aUBTOTA S': $12.50 $405.00 . TOTAL FEE $417.50
Revised: 07/01/2013