12090258CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20750 STEVENS CREEK BLVD CONTRACTOR: TERRA NOVA PERMIT NO: 12090258
INDUSTRIES
OWNER'S NAME: BYER PROPERTIES LP 1607 TICE VALLEY BLVD DATE ISSUED: 09/28/2012
OWNER'S PHONE: 7602681812 WALNUT CREEK, CA 94595 PHONE NO: (925)934-6133
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALS
�Uc' License Class Lic. # THE ISLANDS- INSTALLATION OF PREFABRICATED
U.S�
�G�� b�A / TRAILER
Contractor � l Nb- Date Z FOR TEMPORARY HIRING OFFICE 440 SQ FT
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 corder 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 p it. Additionally, the applicant understands and will comply
with all non-poin souiEe regulations the Cupertino Municipal Code, Section
9.18.
Signature r t Date G 2 D
❑ 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)
I, as owner of the property, am exclusively contracting with licensed 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.
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
Sq. Ft Floor Area: I Valuation: $5000
APN Number: 35908013,00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
s'
Issued by: %>�!✓ �%i'G Date: !2-c2
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:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under 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, Sectim 25,505, 2553 Ond 25534.
Owner or authorized agent: i Date: U1 2K
II
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
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 -point source regulations per the Cupertino Municipal Code, Section
9.18.
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Date
CITY OF CUPERTINO
IA/JI FEE ESTIMATOR — BUILDING DIVISION
20750 Stevens Creek Blvd
DATE: 09/28/2012
REVIEWED BY: Sean
JimADDRESS:
APN:
BP#:
*VALUATION: 1$5,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
USE:
PENTAMATION
PERMIT TYPE:
WORK
Installation of commercial prefabricated trailer for Islands Restaurant temporary hiring office 440 sq ft .
SCOPE
Xlech. Platt Check
Plulid?. Plots Check
Elec. Plait Check
.)-tech. Petwjit Fee:
P177777i). POWlit Fee:
Dec, Permit Fee:
Other hlech. hasp.
Other Phimh hasp.
Outer Elec. lay.
Alech. Lisp. Fee:
Phrriib. hisp. Fee.:
Elec. hasp. Fee:
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary SewerDistrict, School
Dictrirt. oto. )_ Tho.co foo.c aro hacod on the nroliminary information availahle and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resohition 11-053 Eff. 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
i
Suppl. PC Fee: (j) Reg. 0 OT
0,0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
1 0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
C017S11'11ction Tax.
Administrative Fee:
G
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee:
$0.00
0 #
$799.00
Commercial Coach (per unit)
ICOMMCOCH
E)
Tryrnel Documcniolion Fees:
Strong Motion Fee: IBSEISMICO
$1.05
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$2.05
$799.00
TOTAL FEE:
$801.05
Revised: 07/01 /2012