10120128 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1.9676 STEVENS CRK BLVD CONTRACTOR:FIVE STAR PERMIT NO: 10120128
GENERAL CONSTRUCTION CORP
OWNER'S NAME: EVERSHINE GROUP 1781 SWANSTQN WAY DATE ISSUED:03/16/2011
OWNER'S PHONE: 4085157651 SAN JOSE, CA 95132 PHONE NO:(408)313-8299
LICENSED CONTRACTOR'S DECLARATION r F
P BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#^ ( F F
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: T.I TEAR DOWN AND INSTALL WALLS TO CREATE
ADDITIONAL ROOMS 1,060 SQ FT
(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:$15000
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 APN Number:36906009.19676 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 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 FROM LAST 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
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.
C/ �_ Date RE-ROOFS:
Signature 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 I 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)
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 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 25 }25/ 3 and 2553).
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: / / 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,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.
I
Signature Date
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CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 19676 Stevens Creek Blvd. I I
DATE: 12/17/2010 REVIEWED BY: jsg
APN: BP#: *VALUATION: 1$15,000
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY TOTAL PENTAMATION 1 B TI
USE: Commercial Building FLOOR,41REzt: PERMIT TYPE:
WORK
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
B (Tenant Improvements) II-B,III-B,IV,V-B 1,060 $1,893.28 1BTIPLNCK $1,004.08 1BTIINSP
TOTALS: 1,060 $1,893.28 1 $1,004.08
MECH,HOURLY 0 Yes 0 No PLUMB,HOURLY 0 Yes Q No ELEC,HOURLY 0 Yes 0 No
Xfec:h, Plena Check Phimb, Plcru Check Eke.Plan Check
aftchPamiFee: Phonh, Permit Pee: <rlec. Permit F("!.
Oilier Hech. Insp. Other Plumb haute. Ll Other Occ.Insp.
ilech. L1 —I-
Insp,Fee: Numb. hup. Fc'e: Elec.Insp. re:e.
NOTE: These ees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Eff. 7/1/10) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $1,893.28 Select a Misc Bldg/Structure
Suppl.PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $1,004.08
Suppl. Insp.Feer Reg. 0 OT0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Co)tStrcrction KIN
Acoustical Fee: 0 Yes 0 No $0.00 0
Work Without Permit? 0 Yes ) No $0.00 0
Planning Fee: PLLONGRNGC $0.00 G
T r(wel Doctunentorion Feces:
Strom Motion Fee: IBSEISMICO $3.15 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
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SUBTOTALS: 1 $2,901.51 $0,00 TOTAL FEE: ` $2,901,51
Revised: 12/07/2010
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