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15090130I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 19720 STEVENS CREEK BLVD OWNER'S NAME: EVERSHINE VI LP 'S PHONE: 4083431088 LICENSED CONTRACTOR'S DECL``AA�RATION License Class Lic. # Contractor Date 24 1 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: 1. 1 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 th ermit. Additionally, the applicant understands and will comply with all non -poi so e r Mations per the Cupertino Municipal Code, Section 9.18. Signature l 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: 1. 1, 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) 2. 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: 1. 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. 2. 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 permit is issued. s. 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 Code, Section 9.18. Signature Date CONTRACTOR: BARRIOS PERMIT NO: 15090130 CONSTRUCTION 7041 ROSANNA ST DATE ISSUED: 09/21/2015 GILROY, CA 95020 PHONE NO: (408) 337-7664 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ TENANT IMPROVEMENT TO CREATE ACCESSIBLE RESTROOMS (132 SQ FT). Sq. Ft Floor Area: I Valuation: $55000 APN Number: 36906009.19720 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSP CT ON. Issued by: J pquw!ULL� Date: �` i,J�!/ l 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 MATERI.ALS 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 maip4in compliance with the Cupertino Municipal Code, Chapter 9.12 and the alt & Safr4y Code, Sections 25505, 25533, and 25534. agent: g Date: ✓�/ )� 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 ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228• FAX (408) 777-3333 • buildinq(d)cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION [ZALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECTADDRESS /% -�4 fif a�/� APN# -I ? :tI/_'Q,G/?. 7 6 �`\/(//' OWNERNAME Li .� �' L :l PHONE 0y J �r jU ( E-MAIL �C Jr/ J f STREET ADDRE Ci I Y, TATE, ZIP FAX TP'I�s<!1� �?' ! O CONTACT NAME %'/�S, ,( N PHONE /Q Q / /, /9/iX bbl�T�� E-MAIL ♦ krs 7iir7++er✓ STREET ADDRESS /OO/ CITY, STATE, ZIP it `� +AAGG,E /NT FAX ❑ OWNER ❑ OVNER_-B/UIIAER ❑ OWNER AGE/Nr/r ❑ CONTRACTOR IR 'CONTRACTOR ❑ AR/C=CCT ❑ ENGINEER ❑ DEvELOPER ❑ TENANT CONTRACTORNAME A W C S LICENSE NUMBER �� E BUS. LIC# 1O(>'J77sEy COMPANY NAME 4� _1 s /� E-MAIL /`,j FAX �� C �p 47 Tv 1? a V,* C%//Y(J o� STREET ADDRESS CITY, STA/TEE, ZIP PHO ARCHITECT/ENGINEER NAME " r�a A� i�LICENSE NUMBER %� BUS. LIC # COMPANY NAME OWC/�/ TC- c 7 -YE -MAIL 7 ��n `'/� G FAX STREET ADDRESS ��F> �C?G / V CITY, STATE, ZIP �Q / �l / PHONE &/'— DESCRIPTION OF WORK EXISTING E PROPOS USE CONST$- E # STORIES •V/� USE TYPE OCC, SQ.FT. VALUATION (i) EXISTG AREA NEW FLOOR- AREA DEMO AREA TOTAL NET AREA f / I OV `/ " I' L C BATHROOM, KITCHEN OTHER. REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKfPORCH AREA GARAGE AREA: LJDETACH ❑ ATTACH # DWELLINGUrRTS: ISA SECOND UNrr ❑ YES SECOND STORY ❑YES BEINGADDED? JaNO ADDrrION? ''NO PRE -APPLICATION S IF YES, PRO%ME COPY OF NO LETTER Is THE BLDG AN ❑YES EICHLER RECEf�V BY -: � �' �.� 0 Al IAT.UATION: PLANNING APPL R ,� PLANNING AL HOTiEP �'i�'O 'azou #r` a JC `(i e 44A� - By my signature below, I certify to ch oft e follow I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I h �e provi is c ect. 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating t buildin o ctim. I authorize representatives of Cupertino to enter the above -identified party for inspection purposes. /—_ �pp Signature of Applicant/Agent: Date: rip SUPPLEMENTAL 0 TION REQUIRED Q PL CHECK T1PE•x ;` . _ x4 , FQVTII�G SLIE _ New SFD or Multifamily dvv,ellings: Apply for demolition permit for OVER THE COUNTER z BUILDING PLAN REYIER� existing building(s). Demolition permit is required prior to issuance of building f permit for new building. Q0 1 EXPRESS r LA ❑ PNI�LM1GPLANRI VLbW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure sTANnARD � :PURI IcuoRxs _ form if any Hazardous Materials are being used as part of this project. Copy Plarming Approval Letter Meeting with Planning to rr L7 LARGES i x� FIRE DEPT r _ of or prior submittal of Building Permit application. o�A�TraitYExDs�RICT� :�.,� .,.� D-^EIS'VIROI�`NIENT-riLL�HEALTHs-r� <.. Bldg-App_2011.doc revised 06/21/11 M1 CITY OF CUPERTINO FM -,7 FEE ESTIMATOR - BUILDING DIVISION imADDRESS: 19720 Stevens Creek Blvd DATE: 09/21/2015 REVIEWED BY: Sean PC FEES APN: BP#:'VALUATION: $55,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: $0.00 PENTAMATION 1B TI PERMIT TYPE: WORK Tenant Improvement to create accessible restrooms 132 sq ft). SCOPE $0.00 OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA (s.f.) PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,111-B,IV,V-B Other Meeh. Insp. $0.00 Other Elee. lisp. $0.00 Phimb. Insp. Fee: Elec. Insp. Fee: $0.00 Permit Fee: Hourly Only? 0 Yes 0 No $0.00 Suppl. Insp. Fee:Q Reg. 0 OT 1 0,0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 0 $0.00 $0.00 MECH, HOURLY 0 Yes 0 No PLUMB, HOURLY 0 Yes No ELEC, HOURLY 0 Yes 0Na'' A9ech. Plan Check- Phmih. Plan CheckEler. Plan Check AfechPermit Fee: Minh. Permit Fee: Flee. Permit Fee: Other Meeh. Insp. Other Plunih hasp.E17-- Other Elee. lisp. Mech. hisp. Fee: Phimb. Insp. Fee: Elec. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes 0 No $0.00 727 hours Plan Check, Hourly $286.00 ISTPLNCK Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes 0 No $0.00 Suppl. Insp. Fee:Q Reg. 0 OT 1 0,0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Administrative Fee: 0 0 Work Without Permit? 0 Yes 0 No $0.00 Advanced Plannin Fee: $0.00 ® hours Inspections $572.00 ISTINSPInspection, Hourly 0 0� Travel Documentation Fees: Strong Motion Fee: IBSEISMICO $15.40 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $3.00 SUBTOTALS: $18.40 $858.00 ;`.. TOTALFEE: $876.40 Revised: 07/02/2015