12020013BUILDING ADDRESS: 20650 VALLEY GREEN DR
CONTRACTOR:DEVCON PERMIT NO. 120200 t3
CONSTRUCTION INC
OWNER'S NAME: SI 50 LLC
690 GIBRALTAR DR DATE ISSUED: 02/03/2012
OWNER'S PHONE:
MILPITAS, CA 95035 PHONE NO: (408)942-8200
_— —_
JOB DESCRIPTION: RESIDENTIAL V �O iERCIALa
LICENSED CO� �RACTQ�WSDECLARATIQN
t
License Class Lic.
TJ PREP NON-STRUCTURAL OFFICE SPACE 11,37(a SQ FT
Contractor Date
I hereby affirm that I am licensed tinder the provisions of apter9
(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 kinder penalty of per 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 whiclithis permit is issued.
Sq. Ft Floor Area: Valuation: $30000
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the perforniance of the work for which this
AP N Number: 32610053.00 Occupancy Tvpe:
permit is issued,
r!!�
—
APPLICANT CERTIFICATION
I certify that I have read this application and suite 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 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
180 D M LAST CALLED IN N.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
;
costs, and expenses which may accrue against said City in consequence of the
Date.
gra"un. A nting of this per . t ditionally, the applicant. understands and will comply
�?gulafions
with all non -point per the Cupertino Municipal Code, Section
9,18,
ICE 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.
13 a=VNER-BUILDER DECLARATION
DECLA
Signature of Applicant: Date:
I hereby affirm that I ant exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTE R
1, as owner of the property, or my employees with wages as their sole comfensation,
will do the work, aid the structure is not intended or offered for sate (Sec,7044,
Business & Professions Code)
1, as owner of the property, ant exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec .7044, Business &, Professions Code).
I have read tire hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505,25533, and 25534. 1 will
I hereby affirm under penalty oftnerjury one of tire 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 lklo. rker'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 contanduants as defined by the Bay Arco Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance 'With the Cupert' Municipal Code, Chapter9.12 and
C
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sectious;5 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which, this
permit is issued.
Owner or authorized agent:
1 certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any tranner so as to become subject to the Worker's
Compensation laws of California,. If, after making this certificate of exemption, I
CONSx4CTION LENDING AGENCY
become subject to the Worker's Compensation provisions of tine Labor (-',ode, 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, Cry C.)
Lender's Name
APPLICANT CERTIFICATION
Under'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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses whidi 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 regulatims per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
NOTE. Thiv estimWedoes not indudefees dace tar other Departments (Le, Planning, Public Works, Fire, SanitarpSewer Distriet, School
vistriet, eta). i fi6Se eeS are basea on we rear 1
wortuation aviiiiame ana are oiup an estimate. f-ontact me iYep, tor a in 0.
FEE ITEMS LF'ee R'e5oluflon I_ 0
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
1 #
$380.001
Tenant In iprovement Prep
ITIPREP
Suppl, PC Fee: (D Reg. 0 OT
0.0
hrs
$0.00
PIVIE Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp, FeeReg.
0 OT
hrs
$0.00
PM E Ut ii t Fee-
$0.00
PME Permit Fee:
$0.00
Work Without Permit? 0 Yes (D No
$0.00
Advanced Planning- Fee:
$0.00
Select a Non -Residential
Building or Structure
5-Lro "LL112-1 J —OD-F, —CC:
IBSEISMICO
$6.30
Select an Administrative Item
Bld Stds Commission Fee: IBCBSC
$2.001
SUBTOTALS:
$8.301
$380.00
TOTALSEE.
TWINSIMM