12080264CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20400 STEVENS CREEK BLVD
CONTRACTOR: PACIFIC SURFACING INC
PERMIT NO: 12080264
OWNER'S NAME: CUPERTINO CITY CENTER BUILDINGS
2066 WARM SPRINGS CT
DATE ISSUED: 09/26/2012
OWNER'S PHONE: 6509313400
FREMONT, CA 94539
PHONE NO: (510)440-9494
LICENSED CONTRACTOR'S DECLARATION
r r �
BUILDING PERMIT
i- S � ��{�
License Class C �J Lie. 4 u 7
INFO: BLDG ELECT PLUMB
MECH RESIDENTIAL COMMERCIAL
�,
Contractor & G k<_ 3�1 �aL, vg S13 f I Z
Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: COMMERCIAL BUILDING - SIDEWALK REPLACEMENT
(commencing with Section 7000) of Division 3 of the Business & Professions
TO MEET
Code and that my license is in full force and effect.
TITLE 24 STANDARDS/ACCESS
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
Sq. Ft Floor Area:
Valuation: $18000
permit is issued.
APPLICANT CERTIFICATION
APN Number: 36901028.00
Occupancy Type:
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,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non -point source regulations per the Cupertino Municipal Code, Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18, i
Signature Date—� 1 Oj
�1
Issued
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
RE -ROOFS:
the following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1, as owner of the property, or my employees with wages as their sole compensation,
installed without first obtaining an inspection, I agree to remove all new materials for
will do the work, and the structure is not intended or offered for sale (Sec.7044,
inspection.
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
Signature of Applicant: Date:
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
permit is issued.
Safety Code, Section 25532(a) should I store or handle hazardous material.
i certify that in the performance of the work for which this permit is issued, I shall
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
lot employ any person in any manner so as to become subject to the Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Compensation laws of California. If, after making this certificate of exemption, I
Health & Safety Code, Sections 25505, 25533, and 25534.
)ecome 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.
Owne uthm ized lgent: Z
� Date:
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
,orrect. I agree to comply with all city and county ordinances and state laws relating
I hereby affirm that there is a construction lending agency for the performance of Nwrk's
o building construction, and hereby authorize representatives of this city to enter
for which this permit is issued (See. 3097, Civ C.)
ipon the above mentioned property for inspection purposes. (We) agree to save
Lender's Name
ndemnify and keep harmless the City of Cupertino against liabilities, judgments,
,osts, and expenses which may accrue against said City in consequence of the
Lender's Address
;ranting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
).18.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
signature Date
Licensed Professional
����,,��������,,��,��, CITY OF CUPERTINO
F,w---7 FFF FNTIMATOR — BUILDING DIVISION
ADDRESS: 20400 Stevens Creek Blvd
DATE: 08/27/2012
REVIEWED BY: Sean
APN:
BP#: %v��tj
-VALUATION: $18,000
PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
PENTAMATION 1GENCOM
PERMIT TYPE:
USE:
WORK
SCOPE
,..._.......__,
Xtech, Plan Check
Phrnrb, Phw Cheelf
Elec. Plan Check
l-tctch. Perim[ Fee:
Phnxb. Peonit Fee.
Elec. Permi7 Fee:
011ter rl9ech. Insp.
Other
Other Plrnhab Insp,EIF
Other Elec. In-
insp. Fee:
Phtnrb, hr.V). Fee:
Elec. Insp. Fae:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
1. 17 4. 1.*- /.F ni,.. mrnilnhlo and aro nnh)an o.ctLntatn_ Contact the Devt for addn'l info.
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FEE ITEMS (Fee Resohltion 11-053 Eff. 711111)
... I ... ........... ... .........-
FEE
.----- --- -
QTY/FEE
- - --
- --- - -
MISC ITEMS
Plan Check Fee: Hourly Only? ® Yes (!) No
$0.00
hours Plan Check, Hourly
$133.00 1sTPLlvcx
A
Suppl. PC Fee: � Reg. () OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? ()Yes Q No
$0.00
Suppl. Insp. Fee:(F) Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
L
Corlstrnction TUY.'
Alrninisiralive Fee:
G
Work Without Permit? ® Yes No
$0.00
Advanced Planning Fee:
$0.00
L�J hours Inspections
$399.00 ISTINSP Inspection, Hourly
G
®'A
Trave./ Docrnrrentotiort Pees.
Strong Motion Fee: IBSEISMICO
$3.78
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS: `
$4.781
$532.00
TOTAL FEE:
1
$536.78
Revised: 07/01 /2012