09120143I CITY OF CUPERTINO BUILDING PERMIT I
I BUILDING ADDRESS: 21741 STEVENS CREEK BLVD I CONTRACTOR: FREELAND URI PERMIT NO: 09120143' 1
OWNER'S NAME:
11 LICENSED CONTRACTOR'S DECLARATION
License Class Lic.4
Contractor
Date
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 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
permit is issued.
APPLICANT CERTIFICATION
I cenify 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.
Signature
Date
OWNER -BUILDER DECLARATION
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,
wi I I 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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under 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
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
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 cenify 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.
W2, -J/0 7
21741 STEVENS CREEK BLVD DATE ISSUED: 12/23/2009
CUPERTINO, CA 95014 PHONE NO:
JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIALU
LEGALIZE AS BUILT 62 SQ FT LUNCH ROOM INCLUDE
(E)
LIGHTING ACCESSIBILITY UGRADE
Sq. Ft Floor Area: I Valuation: $1000
APN Number: 32620048 1 Occupancy Type:
PERMIT EXPIRES IEF WORK IS NOT STARTED
WITB[IN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Date: -1'2 -22,15
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. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(s) 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. Date:
Owner or authorized agent:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCff1TECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21741 STEVENS CREEK BLVD I CONTRACTOR: ZHU PING WANG PERMIT NO: 09120143
I OWNER'S NAME: ZHU
INO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#.
Contractor
Date
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 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
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 permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18. 1
�1,;-'F� 1�� dry
Signature v ' `- f Date
❑ 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 under 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.
1 certify that in the performance of the work for which this permit is issued, I shall
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
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
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 Cpde, Sect on
9.18. f !'1 /' , I / -,a
MECH r RESIDENTIAL F_ COMMERCIAL r
JOB DESCRIPTION: LEGALIZE AS BUILT 62 SQ FT LUNCH ROOM INCLUDE (E)
LIGHTING ACCESSIBILITY UGRADE
10/16/12- REV#1 - REVISE FACIAL ROOM 62 SQFT-ISSUED 2/19/13
Sq. Ft Floor Area: I Valuation: $2000
APN Number: 32620048 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without fast 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. 1 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, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date:
ti
r f j
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of worles
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
1PIPVi.-F.gT11MAT0R — BUILDING DIVISION
21741 SCB
DATE: 10/16/2012
REVIEWED BY: SYLVIA
liaADDRESS:
APN:
BP#: 09120143
"VALUATION: $1,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
Commercial Building
PENTAMATION 1 GENCOM
PERMIT TYPE: AI
USE:
WORK
REVISION #1- REVISE FACIAL ROOM 62 SQ FT
SCOPE
Xfech. Plan Check
Phunb. Plc? Checl;
Elec. Plan Check
kfech. Pel.110 Fee:
Pknnb, Perini! Fee;
Elec. Permit ree:
-EIF-t-
Other ilder/a, Insp,
0/her P/unib Insp.
Other Elec. Insp.
Akeh. Insp, Fee:
Phtnib. hap, Fee:
Elea, hasp. F,a:
NOTE: This estimate does not include fees due to other Departments (i.e. rtannulg, ruot►c -fronts, -fire, Surtnmy 5e,ve..,,�., ������•
Contact the Dent for addn'l info.
v/srrrey ere . lnese ees lire nliaeu un .nc ..........ua
FEE ITEMS (Fee Resohition 11-053 Eff. 7111121
... v. ,,..... ,..........
FEE
.....- •-. _
QTY/FEE
_--- ---- ----
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes (j) No
$0.00
1 /- I hours Plan Check, Hourly
$266.00 1sTPLNCK
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? 0 Yes Q No
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Constriction Tax:
Achninistralive Fee:
0
E)
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee:
$0.00
L hours Inspections E)
$133.00 ISTINSP Inspection, Hourly 0
Thwel Docomentalion Fees:
Strong Motion Fee: IBSEISMICO
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.50
$399.00
TOTAL FEE:
$40 .50
Revised: 10/01/2012