12030031CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 20650 VALLEY GREEN DR
OWNER'S NAME: SI 50 TLC
OWNER'S PHONE: 4156262937
11 LICENSED CONTRACTOR'S DECLARATION
License Class. Lic, Z'
Contractor Date
1 hereby affirm ;tat I am licensed under the provisions of Chapter 9
(cornmencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirin 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,*-hich 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. 91�
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 hartriless the City of Cupertino against liabilities, judgmerats,
costs, and expenses which may accrueagainst said City in consequence of the
granting of this perruit. Additionally, the applicant understands and will comply
with all non-poi"I's per the Cupertino Municipal Code, Section
9A8.
Signature_ Date
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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 I icensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm tinder 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.
[ 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 pertnit is issued, I shall
not employ any person in any aranner 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
itidernmty 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 -point source regulatioris per the Cupertino Municipal Code, Section
9A&
CONTRACTOR: DEVCON CONSTRUCTION PERMIT NO: 12030031
INC I
690 GIBRALTAR DR I DATE ISSUED: 03,106/2012
MILPITAS, CA 950.35 1 PHONE NO: (408)942-8200
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECH r RESIDENTIAL r COMMERCIAL r
6'71-
JOB DESCRIPTION: APPLE- COMMERALT)ANT IMPROVEMENT
PREP(5400SQFT)OFFICE SPACE;NON-STRUCTURAL //1&9/,97 4 zP~ 0
Sq. Ft Floor Area: I Valuation: $81000
APN Number3261005100 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYSWROM LAST CALLED INSPECTION.
MW
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 Applicant: Date:
EIAZARDOUSMATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of tire
California Health & Safety Code, Sections 25505,25533, and 255.34. 1 will ruaintam
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.
Owner
: I
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of morles
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I unlerstatid my plans shall be used as public records.
Signature -- Date--- I Licensed Professional.
AvoRK I U. prep comm. off4cre-space non stuctural.
SCOPE I J"(Am,, A - -I., i rvb n /, . _ L - - - - "
I 'VOT E. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
11bark,t- otr.)_ ThAw fozmaro hawdon the nroroan am infnrenado n avallahle and are ank an estimate. Cnnloel the Dent farad&i'l infin.
FEE ITEMS (Epe Resolution- H&'L" L_y 7"11LI)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
1 #
$380.00
Tenant Improvement Prep
Suppl. PC Fee: (D Reg. 0 Off"
().0
firs
KOO
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee.0 Reg. :0:0T:[Ej
hrs
$0.00
. . .....
Ply E Unit Fee:
$0.00
PME Permit Fee:
$0.00
Work Without Permit? 0 Yes (D No
$0.00
Advanced Pla: n.jtLig Fee-,
.00
Select a Non -Residential
Building or Structure
0
0
St IRSEISAffCO
.i UiotiqjMVjgLfif..on.Fee:
$17.01
Select an Administrative Item
Btci clS Cornfrussion Fee: IBCBSC
$4.00
SUBTOTALSS:
$21.01
$380.00
TOTAL FEE:, $401.01
U-01min 4