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12080300CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1160 S STELLING RD CONTRACTOR: SAN JOSE GOSPEL PERMIT NO: 12080300 PIONEERS INC OWNER'S NAME: SAN JOSE GOSPEL PIONEERS INC PO BOX 892 DATE ISSUED: 08/28/2012 OWNER'S PHONE: 6508048783 CUPERTINO, CA 95015 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # MECH r RESIDENTIAL r COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE AND REPLACE WINDOWS NON-STRUCTURAL (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. Sq. Ft Floor Area: Valuation: $3000 f 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: 36225029.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities, judgments, 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by _ Date:�� 7� 9.18. S ignature Date RE -ROOFS: Jam` OWNER -BUILDER DECLARATION PL 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER construct the project (Sec.7044, Business & Professions Code). hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self -insure for Worker's California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain Compensation, as provided for by Section 3700 of the Labor Code, for the compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & performance of the work for which this permit is issued. Safety Code, Section 25532(a) should l store or handle hazardous material. I have and will maintain Worker's Compensation Insurance, as provided for by Additionally, should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code, for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued, I shall Health & Saf Code, Sections 25505, 25533, and 25534. 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 Own or thorize gent: Date: 828 f 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. NSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued (Sec. 3097, Civ C.) I certify that 1 have read this application and state that the above information is Lender's Name 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 Lender's Address 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 ma rue against said City inconsequence of the ARCHITECT'S DECLARA'T'ION granting of this permit. A Wally, the applicant understands and will comply I understand my plans shall be used as public records. with all non -point sou gulations er the Cupertino Municipal Code, Section 9.18• Licensed Professional Signature DateZt3 I CITY OF CUPERTINO FM -7, FEE ESTIMATOR — BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. eta). These fees are based on the nrelfminary information available and are only an estimate Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eft' 7/1/11) ADDRESS: 1160 s. stelling DATE: 08/28/2012 REVIEWED BY: bobs. Phrmb. Plan Cheek APN: BP#: `VALUATION: 1$3,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building USE: I PENTAMATION 1GENCOM PERMIT TYPE: WORK remove and replace windows non structural. SCOPE NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. eta). These fees are based on the nrelfminary information available and are only an estimate Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eft' 7/1/11) FEE QTY/FEE Mech. Plan Check Phrmb. Plan Cheek Elec. Plan Check ill, r. Permit Fee: 'Fill, PfumbPermit Fee: Efec. Permit Fee: Other Afech. Insp, Other Plumb Insp. Ocher Elec. Insp. Li Alech. Insp. Tre: Plumb. hr.y. Fee. Elec. Insp, Fre: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District. eta). These fees are based on the nrelfminary information available and are only an estimate Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eft' 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 8 # $400.00 Window / Sliding Glass Door I WINREP Replacement Suppl. PC Fee: (D Reg. Q OT 0.0 1 firs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee -.0 Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Zrt.r: ,4dininL.str-ative Fee: 0 Work Without Permit? © Yes E) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure E) i Travel Doc-umentation Fees: Strong Motion Fee: IBSEISMICO $0.63 7 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.001 SUBTOTALS: $1.631 $400.001 TOTAL FFE: $401.63 Revised: 07/01/2012