12060030 • r
CITY OF CUPERTINO BUILDING•PERMIT
r -
'BUILDINGADDRESS: 2045Q;STEVENS,CREEK"BLVD CONTRACTOR:I-DPR,CONSTRUCTION;A `PERMIT NO; 12060030
GENERAL
OWNER'SNAME; CUPERTINOICITY,CENTER•BUILDINGS 1450 VE .BLTERANS. Vp DATE ISSUED:,03'/29/013}
OWNER?,S'.P,HONE: :46.9 73.612_f REDWOOD.CITY;,CA 9406.Y PHONE NO:(650)4.74-1450
LICENSED CONTRACTOR'S.DECLARAT30N JOWDESCRIPTION' RESIDENTIAL COMIGIERCIALO '
L cense Class.`7 Lic.# 4 LAB`126-FLOOR 3&4.-INSTALL NEW'.CHAMBER
'EQUIPMENTINTO,,3 NEW CHAMBERS
Contractor (;0N5, (2 JLA6 ' D'ate. — " ` t `-'
I:herAy'aftiefn.,that lain licensed undet the'proyisions ofCliaptee 9,
(commend ng 'with Section 7000)i'ofDivisioa-3,of,,the Business,&.Professions
o& nd that my licensees ip full forcetana effect.
I,hereby affirm under.penalty'of perjury oiie,ofzthe followin&Wd declaratioosi
I_haveend,will maintairra`cer(ificate'of consenGto self-insure for-W.orker's
Compensation as:proyided,for by+5ectiow3700 of theLabor Code;for the -
perforfnance,of the work,for whi`ch;this,permit,is,issi ed. Sq.'Ft Floor-Area:i Valuation:$5000
thave=and:will maintain Worker sCompensation,Insurance;as provided,for by
' Section•'3700 bf the'LaborCod&forthe perforniance of the work for which this
APN Number:S6 01027.00 Occupancy Type:
permit is issued.
APPLICANTICERTIFI'CATION "
Iycertifythat I have read this application and state:that the above information is, PERMIT EXPIRES.IF wORI{ISNOT'STARTED
correcf.,l agree to comply with alFcityand countyordinancesmnd.state,laws relating
to budding;construction;and hereby authorize representatives of this city to enter WITHIN 180 D ERMIT,ISSUANCE OR
upon,'the above`mentroned.property for.ih pectioiipurposes (We)•agree to save 180 D `_' ;81TR0MJA9T'CALLED INSPECTION.
indemnify,and:keep.harrnless the,City of Cupertino againstliabilities;judgments, _
costs and`.expenses�.w ich may`accrue against,said City in consequenb&6f the
granting"o"f=this"permit. Additionally,the applicant.understands%nd"will comp) ss ate: Z
wit4;all:n6n,point's6urce regul'ations•per the Cupertino_Municipal Code,Section.
9r1'8•.
RE-R
Signature: Date-;- .All,roofs�,shalL,be�.ins ected nor to,an !coo00Finaterial be.ing installed. If a roof is
installed withoutfirst obtaining an inspection,,;l agree`to remove+all rieWmaterials for
iifspection.
0 OWNER-BUILDER DECLARATION
Signature,of Applicant:' Dates,
I hereby-affiirrn'thata am exemPt'from the Contraetor's,License Law for one of
the following two reasons,: AL_L;RQ_OF COVERINGS TO.BE CLASS"A"OR BETTER'
1;gas owner;of the property or my employees"'with wages,as,theif.§61ecompensation,
will do the work;and the structure isnot intended:or offered'for„sale Sec:7044, -”
Business_&3P rofessionsiCode),
I;as.owner�ofthe=-property,arr`rexclusive'y contracting'with,licensed contractors to HAZARDOUS MATERIALS,DISCLOSURE
construcfahe ro"ect. Sec:7044;Business&;ProfesswnsGode: J haver ea Health&:Safe"materials:requiremeuts�under.Chapter 6.95rof the:
P- "J ( ). I have read the•hazardous
t,Code Sections'25505"25533 and 25534: I will
Thereby�affrm und_er,penalty,of perjury ou,.of the,`following three ;maintain,compliancewi6ihe;Cuperhno,Mumcipal Code„Chapter 9:12;and.the
declarations: Health,&Safety Code;;Sectiow25532(a)should I store�or handle,hazardous
l.'have-and will maintain a.C&tificate,of'Consent to self-insure'for:Worker',s `material. Additionall, hould L use"equipment or-devices which emit hazardous
Compensation;as provided for,by Section:3700 of the'LabordCode;for"the air contammaots asd'efined 6y`the Bay.Area,Air Quality'Management Districts
p LL ' p will,mainiam complianeewith,the Cupertino Municipal;Code,Chapter'9.12 and
,performance of thework for which this permit,is issued,
I`have,and'will.niaintaih W,orker"s•Com ensatson Insurance;as' rovided,forby the Health&,Safety Code,Sections 25505;.25533 and 25534.
Section 3.7,00;of the Labor Code'f_or the performance"of the work for which4his
Dater
permit<is issued. Owner or,authorized agent:,
I•certify tha6nlherperformance,of;the work forrWhich'this perm&isissued,T§hall
;"not employ any;peisor m any manner,so as to,become subject to ihe-Worker's
'Compensation:llawssof California: If,after'_rriak ng this cti4jcate.of exemption,I. CONSTRUCTIONLENDINGAGENCY
;become"sulijectdo,the Worker's Compensation provisions ofahe Labor Code,I must ;I hereby;affrm thatthere is•a,construction-lending agency.for'the perforrnance of
forthwith comply with such,provisions ordhis m
peritsh_al-1`-b_a,deeined revoked,_ worksforwhich this permit is.issued(Sec.3097 Civ C.)
Lendeils'Name
APPLICANT CERTIFICATION Lender's,Address.
I certify'that'Lhave;iead this application andstate',thatth6 above',,.inforrnation is
correct:(agree to,comply`wA a-II ci-ty and'county'gldinances and,state laws relating,
to building consfiuctioq�and hereby authorizejrepresentatives ofthis cityto,enter
upon the-.above mentioned property for inspection purposes (We),agrce to save ARCHITECT'S DECLARATION
indemnify and keep;harrrrlessltIii City of Cupertino againstliaBilities;judgments,
,costs,and e-xpenses which�may,acc-rue agamst,said-Cty'i'n consequence of the Lundersfand tnry plans shalfbe`used'.as public+records.
i,ganting{oNhis permit Addiiionally,aheiapplicant understands"and will comply
with all,non pomtsource regulations per the Cupertino;Municipal Code Section Licensed Professional
• Sgriatu"re Date
CITY OF CUPERTINO,
FEE ESTIMATOR- BUILDING DIVISION
:11aAW)RESS: 20450atvns crk blvd'., DATE:. 06/05/2012 RENEWED BY: bob s'.
PN: BP# "VALUATION: $5,000.
VERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration./Addition/ Repair
PRIMARYPENTAMATION
USE:,, Comrnercial'Building PERMIT TYPE'- 1'GENCO
'WORK` install ne3W,cham4er`e ui n ment'into 3 new chambers.
SCOPE
uy �
.�.-k rz m
SLI�u:!t. °Irrn C.7.._rft I'hi%ia;?. Plc;rt C l;r.`,it ' (•':e"r t'htck.
Fll
,t,.%t. /°ram T e: F
Li p="(':
dVOTE:`This estimate;does not include fees ilu'e io other-Departments(ke.Planning;Public Works,Fire,Sanitary Sewer District,School
District;,etc. . These. ees are based onlhe. ieliriiiha" .information available and are:onl.'an estimate. Contact'the De t` or i7ddn'.1 in o.
FEE':ITEMS Tee Resolution.11-053,Eff.`,711ZI./). FEE' QTY/FEE MISC I-TEMS
Plan Check Fee: Hourly Only? '(j)Yes 'O No $0:00 0 hours' Plan Check, Hourly-
Suppl. PC Fee, (2) Reg. 0 OT' 0.0 fits $0.00 $520.00 ISTPLNCk
PME Plan Check: $0.00
Permit,Fee: Hourly Only?. ( Yes 0-No , $0.00
Sup,p , rp ,EQ rslis —. RgOT $0.00
PME Unit,Fee:
$0.00
PME Per-_mit-F,ee $0:00
� r,;alr°i,rtrrrti.:;tr .I
Work Without Permit?, Yes E) No $0.00
Advanced Planning Fee: $0..00 ®,hours Irispecti'ons ,
Ji ct=i E 1 r3e�c:rrn c ;P:;tr„ 1`c e.�: $520,00ISTINSP Inspection,,Hourly
Strom Motion Ree: IBSEISrMIICo $1..05 Select an.Administrative Item
,Bldg,,Stds,Commission Fee:. IBCBSC $1:00
E
"SUBT®TALS $2.Q5 $1,,;040.00 i _ TOTAE K $1,0'42.05
Revised: 05/0:172012