13010022 CITY OF (CUP ER'1TIINO BUILDING PERMIT
BUILDING ADDRESS: 10021 S BLANEY AVE CONTRACTOR. ERMIT NO: 13010022
OWNER'S NAME: PROMETHEUS DS Q s a DATE ISSUED:03/27/2013
OWNER'S PHONE: 6509313457 511 - r :::C �D�-- PHONE N045'`Q•s.�bl
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIALIJ
License Class Lic.# DEMO FOR(1E)STRUCTURE E-5771 SQ FT
Contractor Date
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:$10000'
1 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:36903006.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is PERMP8D
ES IF WORK IS NOT STARTED
correct.1 agree to comply with all city and county ordinances and state laws relating ���� ��®�,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 DAII(LAST CALLED ][ TION.
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. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per 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
installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
I hereby affirm that D 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,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 255�32(a)should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I i s equipment or devices which emit-hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by th ay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance wit tho ertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation.hrsprance,as provided for by the Health&Safety Code,Se tioi s 05,25533,and 25534.
Section-3700 of the Labor Code,for the performance of the work for which this
Owner or authorized. .. Date:
permit is issued.
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,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 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 ntioned property for inspection purposes.(We)agree to save
indemnify and k harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expen which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this it.Additionally,the applicant understands and will comply
with all non. of s cc regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18. -2
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR TOR- BUILDING DIVISION
ADDRESS: 10021 s blaney dr DATE: 1 3 / REVIEWED BY:
APN:. BP#: *VALUATION: $10,000
*PERMUT.TY PE: Demolition Permit PLAN CHECK TYPE:
PRIMARY PENTAMATION
USE: PERMIT Building PERMIT TYPE: 1COMMLDEM
WORK
SCOPE
FEE IID FI,R AREA
s.t.
1DEMOCOM 5,771
Xk,ch. Plan Check Plumb, Plan Check Elea.1'Ian Check
L1ec11. Permil Ice: Plumb. Permit Fee: 71-1lec. Permit Fee:
Orher Meeh.Insp. C piher Plumb Ins[). Outer Elee.Insp.
dlech.Insp. Fev Plumb. Insp. Fee:: Elec.Insp.1,ee:
NOTE.This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.2. TheseLees are based on the relimina information available and are onl an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution I1-053 Eff. 7/1/12) FEE QTY/FEE MISC ITEMS
Plein Check Fee:
Sarp/�I:.PC lei a
Plumh.%Mech./Elec.
Permit Fee: $800.00
Suppl. Insp, Fee.0 Reg. Q OT 0 0 hrs $0.00
Plumb.Afech./Elec
Plumb./Meeh./Elee Permit Fee:
Conslruction Tax.
Administrative Fee:
Work Without Permit?
Advanced Planning Fees:
Travel Documentation Fees: i
Strong Motion Fee: IBSEISMICO $2.10 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $803.10 $0.00 TOTAL FEE: $803.10
Revised: 10/01/2012