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10060091CITY OF CUPERTINO FUILDING PERMIT I BUILDING ADDRESS: 19050 -19088 STEVENS CRK BLVD I COP[TRACTOR: SMI CONSTRUCTION I PERMIT NO: 10060091 I INC "VNER'S NAME: UNITED POLARIS INC OWNER'S PHONE: 4082553999 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor 0,/V f7 Date Vptcr I hereby affirm that I am licensed under the provisi s of C (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,.tKe'City of Cupertino against liabilities, judgments, costs, and expenses whic ay accrue 'against said City in consequence of the granting of this permit A ditionally, the applicant understands and will comply with all non -point rce r ulations per the Cupertino Municipal Code, Section 9.18. mature Date I ❑ 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. 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 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 the above mentioned property for inspection purposes. (We) agree to save ..unify 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. 595 AONTAGUE AVE DATE ISSUED: 06 /15/2010 SAT` LEANDRO, CA 94577 PHONE NO: (510)351 -3288 JOE DESCRIPTION: RESIDENTIAL LJ COMMERCIAL STUCCO REPAIR 3500 SQ FT REPLACE WATER PAPER, PL MOOD IF NEEDED Sq. Ft Floor Area: Valuation: $20000 IAP1I Number: 37507046.ALL I Occupancy Type: I PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPE TIOJ. Issued � Date: i 0 RE- ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is instilled without first obtaining an inspection, I agree to remove all new materials for insl ection. Signature Date I Sig iature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I h; ive read the hazardous materials requirements under Chapter 6.95 of the Ca ifornia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the He dth & Safety Code, Section 25532(a) ould I store or handle hazardous material. Additionally, should I use e t or devices which emit hazardous air contaminants as defined by the y rea it Quality Management District I wil I maintain compliance with the rtino�Municipal Code, Chapter 9.12 and the Health & Safety Code, Sectio s 255 255 and 25534. Ov ner or authorized Date: / I hi;reby affirm that there is a construction lending agency for the performance of wo -k's for which this permit is issued (Sec. 3097, Civ C.) Le ider's Name Le rder's ARCHITECT'S DECLARATION I u iderstand my plans shall be used as public records. Licensed Professional T RTI CITY OF CI PE NO CUPEf�TINO GENERAL BUILDING PERMIT APPLICATION FORM )oo�D0dq APN # 5 0-7 �L �� —1 Date: /� / 0 Building Address: Mailing Address if different from buil (fng address): Are Hazardous Materials being used as part of this pi- oject? Yes No HOA: (Exterior work only) Yes ❑ No If es, pro vide letter from HOA Owner's Name: L L G Phone #: Contractor: Phone: j- /v 3 S-% -3 Fax: - rc,, - / Contractor License #: `3 F3 // 6 Cupertino Business License #: Contact: Phone: S' /o -- 6 gg /a, Fax: Residential mmercial Job Description: 5, -' Building Permit Info: Bldg 3 Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1 -A, 1 -B ❑ II/III/V -A ❑ II/III B, IV -HT, V -B F� A� - - Valuation: s a ,4, ?-o In p 0-rX , Square Footage: Project Size: Express Standard ❑ 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. °oints Achieved: For help, contact Build it Green at www.builditgreen. ur Revised 07/14/09 CITY OF CUPEkTINO CITY OF CU PERTINO GENERAL BUILDING APPLICATION FEE SCH=EDULE Quantity /Sf Fee ID Fee Description Fee Group Permit Type 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) additional stu -,co application B 1 WINREP Replacement windows /sliding glass door (ea 8 windows) B 1 WINMEWSTR New Window - structural shear wall /masonry (includes plan ck fee) B IEPERMITFEE Electrical Permit Fee E IMPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Pei mit Fee P l ELCPLNCK Stand Alone 3lectric Pln Ck (hourly) E I MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone :?lumbing Pln Ck (hrly) P I STPLNCK -(3 Hr Min when not over counter) Standard Plan Check (when no E/M/P) hourly-stand alone B / / 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICR Seismic Resi iential B / 1BSEISMICO Seismic Corr..mercial B 1TRAVDOC Travel & Do,;umentation B 1 BUSLIC Business Lic :nse B 5 of 5 CITY OF CU PERTINO FF,F. FgTIMATOR -R1 JILDING DIVISION ATnTF. Tb - hncad nn Nho nrolb"inary irninrmatinn avaihhle and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS (Fee Resolution 09 -051 Ef: 7/f 1,09) ADDRESS: DATE: MISC ITEMS REVIEWED BY: 00 A PN: BP #: F71 "VALUATION: $20,000 *PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Restucco PRIMARY USE: Commercial Building RESTUCCO WALL AREA $699.00 S.f. APPLICATION 1 R3SFDADD /REM TYPE: xW xa 00 3� ATnTF. Tb - hncad nn Nho nrolb"inary irninrmatinn avaihhle and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS (Fee Resolution 09 -051 Ef: 7/f 1,09) FEE QTY/FEE MISC ITEMS F71 Permit Fee: $699.00 Work Without Permit? Q Yes 0 No $0.0( Strong Motion Fee: IBSEISMICO $4.2( Select an Administrative Item B1dg�Stds Commission Fee: IBCBSC - $1.0(1 SUBTOTALS: $704.20 $0.00 TOTAL FEE: $704.20 Revised: 6/15/2010 CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 37507046.ALL DATE ISSUED.......: 06/15/2010 RECEIPT # ......... BSOOOC10637 REFERENCE ID # 10060C91 SITE ADDRESS .....: 19050 -19088 STEVENS CRK BLVD SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER UNITED POLARIS INC ADDRESS PO BOJ': 1805 CITY /STATE /ZIP ...: CUPER -INO CA, CA 95014 RECEIVED FROM CONTRACTOR ... COMPANY ...... ADDRESS ...... CITY /STATE /ZIP TELEPHONE .... OLIVII� JANG RAYMOND SITU LIC # 25182 SMI CONSTRUCTION INC 595 MO )NTAGUE AVE SAN L:;,ANDRO, CA 94577 (510)351 -3288 FEE ID UNIT QUANTITY AMOUNT PD -TO - - - -DT - - -- THIS REC NEW BAL ---------- ------- - - - - 1BCBSC VALUATION -- ---- - - - - -- ---- 20,000.00 - - - - -- 1.00 0.00 1.00 0.00 1BSEISMICO VALUATION 20,000.00 4.20 0.00 4.20 0.00 1STUCOAPP SQ FEET 2,500.00 635.00 ---- 0.00 - - - - -- - - -- 635_00 - - - -- -0_00 TOTAL PERMIT ---- - - - - -- 640.20 0.00 640.20 0.00 METHOD OF PAYMENT AMOUNT - - - - -- REFERENCE -------------------- NUMBER ----------- - - - - -- --------- CREDIT CARD 640.20 visa --------------- TOTAL RECEIPT 640.20 CUPERTINO CONTRACTOR / SUBCONT CTOR LIST IF Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408 - 777 -3228 Fax: 408 - 777 -3333 JOB ADDRESS: RMIT # (470 ty OWNER'S NAME: f c7 s PHONE # o 2 f '— C GENERAL CONTRACTOR. BUSINESS LICENSE # ADDRESS: — I CITY /ZIPCODE• C' *Our municip6al code requires all businesses working in th(yity to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY S)rION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCO TORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. �� 1—� J .. 1 am not using any subcontractors: Signature to 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 Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date iao� ��i 14v e,14 r t 0 / s- 44,F- � 0� S 7 � (p /- U) Zk 3-.,Z /910so- NOR ,G� e-C-5 C,i eR-I< eui 011-