12050094CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21601 STEVENS CREEK BLVD
OWNER'S
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic.#
Contractor Date
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
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
permit is issued.
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
upon the above mentioned property for inspection purposes. (We) agree to save
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 pen -nit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature.
Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
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
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
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
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
upon the above mentioned property for inspection purposes. (We) agree to save
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
with all non -
�� Date
CONTRACTOR: WONN ANNA TRUSTEE PERMIT NO: 12050094
P.O.BOX 1387 DATE ISSUE,D:05/09/2012
CUPERTINO, CA 95014 PHONE NO:
BUILDING PERMIT INFO: BLDG ''r ELECT ._ PLUMB F_
MECH r RESIDENTIAL 'F COMMERCIAL r
JOB DESCRIPTION: SHARE WORLD - TITLE 24 2010 VAN PARKING
COMPLIANCE
AT EXISTING COMMERCIAL SPACE
Sq. Ft Floor Area: I Valuation: $3000
APN Number: 32660001.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by Date��'��
C.-
RE-ROOFS:
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.
Signature of
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements tinder Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
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
Health & Safety Code, Sections 25505, 25533, and 25534.
: n
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of Nwrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FFF FNTIMATOR — BUILDING DIVISION
LaiADDRESS:
21601 stvns crk blvd
DATE: 05/09/2012
REVIEWED BY: bobs.
APN:
BP#:
*VALUATION:
$3,000
,PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
g
PENTAMATION 1GENCOM
PERMIT TYPE: i
USE:
WORK
Title 24 2010 Van parking compliance at existing commercials ace.
SCOPE
,14c ch. Plon Chec•h
Plumb. Phol Cheek
Dec. Plan Checlr
11,1111/1. Petnril Fee
Plurnh. Permil Fee;
1,77ec, Permit 1°ire:
0/kcr Akch, hjsp.
01l1('r Phfmh hzsh.
Oiher Dec. hasp,
dA�ch. lusp, Fee
Phmuh. Imsp. Fee:
Elec, Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. planning, Public works, Fire, Sanitary Sewer visirlcy acnum
nj.- ..♦ s,. 1 TL..,�., f'.,.,� nrn hnoni7 ns� tl o nroti»fi[[nro infnrn/atinn availahlo and are only an estimate. Contact the Dept for addn'l into.
ct, G[c. ...............
FEE ITEMS (Fee Resolution 11-053 E : 7f /f 1/11)
... ... ......... .. ... ......___
FEE
____._ .._ _
QTY/FEE
_ _-
MISC ITEMS
Plan Check Fee: Hourly Only? Q Yes 0 No
$0.00
hours
$130.00
Plan Check, Hourly
ISTPLNCK
Suppl. PC Fee: Q Reg. Q OT
0.0 1
his
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? 0 Yes No
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
C'ortsllYrction T�r.�:
Ad�rlinistlillive Fee:
0
E)
Work Without Permit? 0 Yes ) No
$0.00
Advanced Plaiinin& Fee:
$0.00
= hours
$130.00
Inspections
ISTINSP Inspection, Hourly
0
0
Travel Doc:to)wnlation Fees:
Strong Motion Fee: IBSEISMICO
$0.63
0.5 hrs
$41.00
Admin./Clerical Fee
lADMIN
Bldg Commission Fee: IBCBSC
$1.00
SUBTOTALS: `
$1.63
$301.00
TOTAL FEE:
$302.63
Revised: 04/01 /2012