12020030CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20373 STEVENS CREEK BLVD
CONTRACTOR: SOUTHEAST
PERMIT NO: 12020030
CONSTRUCTION
OWNER'S NAME: W D V PROPERTIES
14619 JERILYN DR
DATE ISSUED: 05/17/2012
OWNER'S PHONE: 4087384444
SAN JOSE, CA 95127
PHONE NO: (408) 613-3169
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALS
❑ LICENSED CONTRACTOR'S DECLARATION
License Class_ Lic. # i
PINKY - MINOR COMM.T.I BUSINESS SPACE, ADD NEW
?
OFFICE SPACE,(775SQFT);PLUMBING,ELECTRICAL AND
Contractor "t �' l71 � �i5 J t lire , ;, Phte .�
MECHANICAL
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
Sq. Ft Floor Area:
Valuation: $12500
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
APN Number: 31626090.20373
Occupancy Type:
permit is issued.
IV/II
APPLICANT CERTIFICATION -
I certify that I have read this application and state that the above ip'fdrmation 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
)/
F / i �! j
Issued by: J Dater ��' „%
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
G
9.18.
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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 tinder 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(a) 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,
:
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.
Signature Date
CITY OF CUPERTINO
41
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: DATE: 02/07/2012 REVIEWED BY: bobs.
APN: : -�00 'VALUATION:
0o BP#
1 6? 01-, 2z�) $ RC
"PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRINURY Commercial Building PENTAM-ATION
USE: I PERMIT TYPE:
woRic minor T.1 commercial business space, add new office space, plumbing, electrical and plumbi
SCOPE
1B TI
OCCUPANCY TYPE:
TYPE OF
FL R ARE A
PC FEES
PC FEE ID
BP FEES
BP FEE ID
CONSTR.
(s.f.)
B (Tenant Improvements)
II-B,111-B,1V,V-B
0
$0.00
$0.00
I
TOTALS:
0
$0.00
$0.00
Pam PLUMB, HOURLY 0 Yes E) No ELEC, HOURLY 0 Yes E) No
NOTE: This esdinide does nol include fees due to other Departments (1 e. Planning, Public Works, Fire, Sanitary Sewer District, School
Dhiript of,- I Thavo foot/ avo havod api tho firplindmaro) infarmatinn availahl.- and arp mi11 an owimaY.'. ronfart thd, Dmit foraddri'l infn.
.
FEE ITEMS (Fte Resolution 11-053'Ir-ff 711/11)
.
FEE
.........
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes 0 No
$0.00
2 hours Plan Check, Hourly
$260.001 ISTPLNCK 1
Suppt, PC Fee: 0 Reg, 0 OT
L.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? 0 Yes (2) No
$0.00
Suppt. Insp. Fee-0 Reg, 0 OT
10-01
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
...........
0
G)
Work Without Permit? 0 Yes 0 No
$0.00
Advanced PlarminE Fee:
$0.00
4 hours Inspections
0 $520, 01 IST,'NSP Inspection, Hourly
G)
0
A
Ce
Sb-ona Ninfit-m Fee: IBSEISAffCO
V<3t
10
Setect an Administrative Item
Bldg Stds Qonmussmn Fee: IBCBSC
$2.00.
SUBTOTALS:
.35
$ 80.00
TOTAL FEE:
r.$ 89.35
I
Revised: 1/19/2012