11120064 i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19650 STEVENS CREEK BLVD CONTRACTOR:SO CAL RETAIL SERVICES PERMIT NO:11120064
INC
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OWNER'S NAME: EVERSHINE VI,LP 510 CRANE ST UNIT B DATE ISSUED:12/08/2011
OWNER'S PHONE: 9494530888 LAKE ELSINORE,CA 92532 PHONE NO:(714)907-3449
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❑ LICENSED CONTRACTOR'S DECLARATION r r r '
BUILDING PERMIT INFO: BLDG" ELECT PLUMB
License Class Lic.# ' r
'11' MECH RESIDENTIAL COMMERCIAL
ContractorS IJ Date L
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ECOSWAY-INSTALL NEW WINDOW AT EXISTING
(commencing with Section 7000)of Division 3 of the Business&Professions COMMERCIAL BUILDING;NON-STRUCTURAL
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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$8500
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:36906012.19650 Occupancy Type:
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: =� Date '
Signature Date 12449/0*
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
1,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 HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued, compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
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 Owed
a ent:become subject to the Worker's Compensation provisions of the Labor Code,I mustDate:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of NNork's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
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CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
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ADDRESS: 19650 stuns crk blvd DATE: 12/08/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: 1$8,500
'PERMIT TYPE: Building Permit PLA PE: Alteration / Repair
PRIMARYSFD or Duplex ® PENTAMATION 1GENRES
USE: PERMIT TYPE:
WORK install new window at ex. commercial bld structural.
SCOPE
Lit3.
r, , .F"A"' nC.Itt:Sj> I'en;
NOTE.This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the prelinina information available and are onjV an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7,11111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Window/Sliding Glass Door
Suppl.PC Fee: Q Reg. 0 OT 0.0 1 hrs $0.00 $457.00 1WINNEWNST I New(Non-Structural)
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl.Insp.Fee:Q Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
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Work Without Permit? 0 Yes No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential 0
7'i'«`,'el I:Jr3<rrr,t .F ;: rrr,r 1;{ Building or Structure 0
A
Strong Motion Fee: IBSEISMIC 85 Select an Administrativ In
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.85 $457.00 TOTAL FEE: 458.85
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Revised: 12/04/2011
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