13100015 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20705 VALLEY GREEN DR CONTRACTOR:NOVO CONSTRUCTION PERMIT NO:13100015
OWNER'S NAME: CAMPUS HOLDINGS INC 1460 O'BRIEN DR DATE ISSUED:10/01/2013
OWNER'S PHONE: 4089745951 MENLO PARK,CA 94025 PHONE NO:(650)701-1500
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ElCOMMERCIAL11
License Class Lie.# `� `�2 APPLE-T.I.PREP(655 S.F)ATTACHED TO BP#
13090171
ContractorDate lco) f
I hereby affirm that I am licensed under the provision 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:$10000
4 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:32610046.00 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 WITIIIN 180 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 180 DAYS F OM 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 -
e 6 -Date:
granting of this permit. Additionally,the applicant understands and will comply y.._.,
with all non-point source regulationsper the Cupertino Municipal Code,Section
9.18. ..
RE-ROOFS:
Signature Date / ° / All roofs shall be inspected prior to any roofing material being installed.If a roof is
F 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
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(a)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, 33 a 553
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: Date: f
I certify that in the performance of the work for which this permit is issued,I shall F
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: 20705 VALLEY GREEN DR DATE: 10/01/2013 REVIEWED BY: MELISSA
APN: 326 10 046 BP#: � �L�I��S 'VALUATION: $10,000
*PERMIT TYPE: Building Permit PLAN CIIECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1TIPRE A
WORK T.I. PREP 655 S.F ATTACHED TO BP# 13090171
SCOPE
,L1ech.Plan Check phwm h.Plan Check Elcc—Plan Check
17lech.Pezmit Fee: Plumb.Permit Fee: Elec. Pernzir Fee:
Orher,lfech.Insp. Other Plumb hzsp, Li Oiher Elec.Insp.
!Wcch.In p.Fae: Plzrmh. hisp.Pee: El'C.Insp,lee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Theseees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS(Fee Resolution 11-033 E . 7/1113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Tenant Improvement Prep
Suppl.PC Fee: e) Reg. ® OT0.0 hrs $0.00 $405.00 ITIPREP
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:Q Reg. ® OT0 0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Consiruction Tax: F71
Ads lnhi trative-eco:
Work Without Permit? Yes (j) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Trot, e l Doczzn?entaiio17 CeS: Building or Structure
i
Strong Motion Fee: IBSEISMICO $2.10 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $3.10 $405.00 TOTAL FEE-.T $408.10
Revised: 08/01/2013