13010117 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20007 STEVENS CREEK BLVD CONTRACTOR:MARY BATE PERMIT NO: 130101 17
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OWNER'S NAME: MARY BATE 13699 SAI2AHILLS DR DATE ISSUED:03/05/2013
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OR'NER'S PIIONE: 4084252896 SARATOGA,CA 95070 PHONE NO:
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❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT 1 PLUMB 1
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SHAN RESTAURANT-INSTALL(N)HANDSINK,2(N)
(commencing with Section 7000)of Division 3 of the Business&Professions TANDORI OVENS,(N)TYPE II HOOD OVER DISHWASHER.
Code and that my license is in full force and effect. REMOVE ALL(E)WOKS
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.
I 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 Sq.Ft Flom Arca: Valuation:$4200
permit is issued.
APPLICANT CERTIFICATION APN Number:31623093.20007 Occupancy Type:
I certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. "
Signature Date Issued by: � 6 �jl/ Date: ' S
11J/ OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued, contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must O-w4ler or a thorized ag nt:
forthwith comply with such provisions or this permit shall be deemed revoked. ate:
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is 1 hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHI'TECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. �b n I understand my plans shall be used as public records.
( 13
Signature
Signature C Date v 4 Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20007 STEVENS CREEK BLVD DATE: 01122/2013 REVIEWED BY: MELISSA
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APN: 31623093.20007 BP#: 1�7 *VALUATION: $4,200
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1CMAP�
WORK INSTALL .N HANDSINK 2 N TANDORI OVENS N TYPE II HOOD OVER DISHWASHER.
.SCOPE REMOVE ALL (E)WOKS
Mech.Plan Check0.0 hrs $0.00 Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
Mech.Permit Fee: IMPERMIT Plumb.Permit Fee: IPPERMIT Elec. Permit Fee:
_L_Other Mech.Insp. 0.0 hrs $45.00 Other Plumb Insp. ETrs $45.00 Other Elec.Insp. Li
11ech.Insp,Fete: Phtncb. hl,). Free: Elec,Lisp.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,fees are based on the prelindna information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resoh*lion 11-053 Ejf. 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 # Mechanical
Suppl. PC Fee: Q Reg. 0 OT O.01 his $0.00 $133.00 ]MCHOOD Hood,Mech.Exhaust
PME Plan Check: $0.00 0 # Plumbing
Permit Fee: $0.00 $10.00 IBPFIXTURE Fixture set on One Trap
Suppl. Insp.Fee:Q Reg. 0 OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $90.00
Conslrirclion Tox.
Administrative Fee: ]ADMIN $42.00 0
Work Without Permit? 0 Yes 0 No $0.00 G
Advanced Plannin lee: $0.00 Select a Non-Residential G
Travel Documentation Fee: ITRAVDOC $45.00 Building or Structure 0
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Strong Motion Fee: IBSEISMICO $0.88 Select an Administrative Item
Bldg Stds Commission Fee: ]BCBSC $1.00
SUBTOTALS: $178.88 $143.00 TOTAL FEE $321.88
Revised: 10/01/2012
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