10020054e—
CITY OF CUPERTINO BUILDING PERNIIT
BUILDING ADDRESS: 19060 STEVENS CREEK BLVD
CONTRACTOR: SMI CONSTRUCTION
PERMIT NO: 10020054
INC
OWNER'S NAME: UNITED POLARIS INC
595 MONTAGUE AVE
DATE ISSUED: 05/26/2010
OWNER'S PHONE: 4082553999
SAN LEANDRO, CA 94577
PHONE NO: (510)351-3288
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL11
-❑ LICENSED CONTRACTOR'S DECLARATION
License Class_ Lic. # 3731 11619*
REPLACE EXTERIOR LIGHTING *COMM BLDG
,Contractor�j I Date�-�r
I hereby affirm that I am licensed under the provisio s
(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
Sq. Ft Floor Area:
Valuation: $6000
performance of the work for which this permit is issued.
1 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: 37507046.19060
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which ma accrue against said City in consequence of the
Z U
granting of this permit. Ad iom Ily, the applicant understands and will comply
Issued b Date
with all non-point sour gut i s per the Cupertino Municipal Code, Section
9.18._
RE-ROOFS:
Signature_ %' ' Date %i
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
f
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should tore or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's
material. Additionally, should I use equipme or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Are Air Qu51ity Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cup mo nicipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the health & Safety Code, Sections 2 5, 533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Owner or authorized agent: % Date- 6 /
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
CONSTR CTION 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
Lender's Address
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 prope or inspection purposes. (We) agree to save
indemnify and keep harmless t City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which m�, accrue against said City in consequence of the
1 understand my plans shall be used as public records.
granting of this permit. d tion he applicant understands and will comply
with all non-p/�nto9.18. Cupertino Municipal Code, Section
Licensed Professional%Signature
Date "21Z ID
0
s
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CITY OF CUPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # a-7 �� 67 q c)
Date: 9 /
Building Address: a,-4.0 4.0 � � l51 VA 64 f .f -v l zl-
Mailing Address (if different from building address): P �� S�v�
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: Exterior work only) Yes ® No ❑ If yes, provide letter from HOA
Owner's Name: '
Phone #: � � Q
Contractor:
SM Z-
Phone:
Fax: f
Contractor License #:�
Cupertino Business License #:
Contact:
Phone:
Fax: V 3' p
Residential ❑ Commercial
Job Description: c�
Building Permit Info:
Bldg Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-8 ❑ II/III/V-A ❑ II/III B, IV -HT, V -B
Valuation: Square Footage:
Project Size: Express [e"S"iandard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgreen.org
Revised 07/14/09
i
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CITY OF
CUPEf�TINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Permit Type
Group
1GENRES or
1GENCOM
1 BBOILERI
For the installation or relocation of ea
M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
1BBOILER2
Installation /relocation of ea
M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1BBOILER3
Install ation/relocation of ea
M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1 BBOILER4
Installation/relocation of ea
M
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1BBOILER5
Installation/relocation of ea boiler or
M
-
refrigeration compressor over 50
7
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH
For ea appliance or piece of equip
M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
1ELECINSP
Other Electrical Inspections (per hour)
E
1MECHINSP
Other Mechanical Inspections (per
M
hour)
1PLMBINSP
Other Plumbing & Gas Inspections
P
(per hour)
1 MEETINGI HR
Application Meeting
B
2 of 5
u�rv.
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CITY Of
CUPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT #
O c -
OWNER'S NAME: o — —
PHONE # l o —
GENERAL CONTRACTOR x
FAX #
I am not using any subcontractors:
4Z
Signature- Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
Date
=ile Edit Actions Details Links Favorites Help
of tir.r 1 7J ! l
PFrn.it
Permit Number x
10020054
I Address " 19060 STEVENS CREEK BLVD
OK
Status
:: ,::
CitylState/Zip CUPERTINO CA 95014
Back
Master Number
jqj Notes
4
APN 37507046.19060
I Contractors I`
Project
jQ�
Unit
Apply Date x
0210912010 Operator
patgFees
Permit Issue Dake
0512U2111 Operator
SylviaM
I Owner Name'l UNITED POLARIS INC
I�-;� Plan Reviews
Certificate Issued
1 211 41201 0 Operator
bobg
Use Default
Inspections
Certificate Type
CC - CERTIFICATE OF COMPL
Address Home - PO BOX 1805
Certificate Number
Print Permit
CitylStatelZip CUPERTINO CA CA 95014
IfY Adjustments
Permit " Property
Zoning Applicant Contractor
Defined Fields
II Holds
Permit Details
PurposelSpecial Conditions
['713 Copy Permit
Permit Type "
1G - ENCOM Q
REPLACE EXTERIOR LIGHTING @COMM BLDG
I Close Permit
COMMERCIAL GENERAL BUILDING
I a Overrides
Usage Class
111111 B, jQj
*SEE NOTES*
111111 B, IV -HTV -B NEW
Supplemental Fields
Applied Value %
6000
FILMED 6/2011
r 1 Notes
SQUARE FT.
0
Calculated Value
_
01
I� Attachments
US C-404 Type
437 jQl
ALT: NON -RES, NON-HSKPG
Permit Form
AUTOPERM -PERMIT
Ownership
1 - Private
Project Size
STANDARD -STANDARD
Iro Add Default T
lermit issued 0512612010
C`�F
anter permit status