10090006CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19648 STEVENS CREEK BLVD
CONTRACTOR: CLEVENGER &
PERMIT NO: 10090006
ASSOCIATES INC
OWNER'S NAME: EVERSHINE GROUP
4848 SAN FELIPE RD STE 150-527
DATE ISSUED: 01/05/2011
ER'S PHONE: 4083246926
SAN JOSE, CA 95135
PHONE NO: (408) 509-5136
❑ LICENSED CONTRACTOR'S DECLARATION
r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. #
r r r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION:ONE POT RESTAURANT - COMM'L TI A-2 OCC
(commencing with Section 7000) of Division 3 of the Business & Professions
1739SQ TYPE
Code and that my license is in full force and effect.
III & V EXISTING BLDG 1977 SPRINKLERED INCLUDE
MECH/ELEC/PLUMBING; NO RE -ROOF (PATCHING EXISTING
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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: $175000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
ANN Number: 36906009.19648
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 NAYS 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.
Issued b - Date:
y'v
Signature Date
OWNER -BUILDER DECLARATION
hereby affirm that 1 am exempt from the Contractor's License Law for one of
ROOFS:
All roots shall be inspected prior to anyy roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, 1 agree to remove all new materials for
I, as owner of the ro
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:
1, as owner of the property, am exclusively contracting with licensed cont;4crs 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:
I have and will maintain a Certificate of Consent to self -insure for Worker's
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
1 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
1 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 1 store or handle hazardous material.
permit is issued.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 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, t must
forthwith
Owner or authorize t / !N O
Date:.
comply with such provisions or this permit shall be deemed revoke t
L.—
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I 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
irr,4Pmnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
and expenses which may accrue against said City in consequence of the
g.....ting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
ARCHITECT'S DECLARATION
9.18• q
! 1
1 understand my plans shall be used as public records.
Signature Date 1 ` "I
Licensed Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19648 STEVENS CREEK BLVD
CONTRACTOR: CLEVENGER & PERMIT NO: 10090006
ASSOCIATES INC
OWNER'S NAME: EVERSHINE GROUP
4848 SAN FE LITE RD STE 150-527 DATE ISSUED: 01/05/2011
OWNER'S PHONE: 4083246926
SAN JOSE, CA 95135 PHONE, NO: (408) 509-5136
❑ LICENSED CONTRACTOR'S DECLARATION
r— r—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION:ONE POT RESTAURANT - COMM'L TI A-2 OCC
(commencing with Section 7000) of Division 3 of the Business & Professions
1739SQ TYPE
Code and that my license is in full force and effect.
III & V EXISTING BLDG 1977 SPRINKLERED INCLUDE
MECH/ELEC/PLUMBING; NO RE -ROOF (PATCHING EXISTING
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 Floor Area: Valuation: $175000
permit is issued.
APPLICANT CERTIFICATION
APN Number: 36906009.19648 Occupancy Type:
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
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.
d y
Issued by;,�=,RDate: /J
Signature Date
�
"'
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
ROOFS:
All roofs shall be inspected prior to anyy 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
1, 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)
Sig;tpture of Applicant: Date:
I, as owner of the property, am exclusively contracting with licensed cont�jc ors to
construct the project (Sec.7044, Business & Professions Code). i`
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
HAZARDOUS MATERIALS DISCLOSURE
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.
permit is issued.
Additionally, should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued, I shall
contaminants as defined by the Bay Area Air Quality Management District I will
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
Owner or authorized a ent:
Date:_
forthwith comply with such provisions or this permit shall be deemed revok
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I 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
with all non -point source regulations per the Cupertino Municipal Code, Section
ARCHITECT'S DECLARATION
9.18. f .
%
I understand my plans shall be used as public records.
Signature Date _ \ / � t/� I
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
ADDRESS:
DATE:
REVIEWED BY:
PC FEE ID
APN:
BP#:
`VALUATION: 1$175,000
xPERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE:
TOTAL
FLOOR ,AREA;
PENTAMATION
PERMIT TYPE: 1A T�
WORK
Elec. Insp, Fee:
SCOPE
1�
$126.00
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
A (Tenant Improvements)
II-B,111-B,IV,V-B
1,739
$2,199.25
IATIPLNCK
$999.80
1ATIINSP
Elec. Insp, Fee:
$126.00
1�
$126.00
Mechanical
IMCRAA Heating System
Permit Fee:
$999.80
Suppl. Insp. FeelD Reg.
0 OT
10701hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$42.00
Consirmlion TaxT-1
TOTALS:
1,739
$2,199.25
1
$999.80
$0.00
MECH, DOURLY (F) Yes ® No
PLUMB, HOURLY Q Yes Q No
ELEC, HOURLY ® Yes (F) No
Mech. Plan Check r,.0 hrs $126.00
Plumb. Plant Check
Dec. Plan Chcc%
IMECPLNC Fmech, Permit Fee: IMPERMIT
Numb, Pel rni! Fee;
Elec. Penni? pore:
Other Mech. Insp.0.0 hrs $42.00
Ober Plninb NVQ .
Other Elec. Insp.
Alech. Insp, Fee:
Ptrmrb. fay. Fee:
Elec. Insp, Fee:
NOTE: These fees are based on the nreliminary infnrnmtion availahly and aro nnh an actimato ('nntnrt tho Wont fnr nddn 1l infn
FEE ITEMS (Fee Resolution 09-051 E . 7/1/10
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,199.25
2 #
$252.00
Mechanical
IBCAIRHA Air -Handling (<=10K cfm)
Suppl. PC Fee: G Reg, 0 OT
f 0.0
hrs
$0.00
PME Plan Check:
$126.00
1�
$126.00
Mechanical
IMCRAA Heating System
Permit Fee:
$999.80
Suppl. Insp. FeelD Reg.
0 OT
10701hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$42.00
Consirmlion TaxT-1
Acoustical Fee:
0 Yes 0 No
$0.00
E)
Work Without Permit? 0 Yes E) No
Plamiili Fee:
PLLONGRNGC
$0.00
Select a Non -Residential G
Building or Structure
Travel Documentation Fee: ITRA VDOC
--$42:0V
Strong Motion Fee:
1BSEISMICO
$36.75
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$7.00
SUBTOTALS:
$3,452.80
$378.00
TOTAL FEE:
1 $3,830.80
Revised: 8/17/2010