14010089CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20080 STEVENS CREEK BLVD
CONTRACTOR: JOHNSTONE MOYER,
PERMIT NO: 14010089
INC.
OWNER'S NAME: PREG BILTMORE
1720 S AMPHLETT BLVD STE 250
DATE ISSUED: 02/05/2014
OWNER'S PHONE: 6509313457
SAN MATEO, CA 94402
PHONE NO: (650) 570 -6161
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALL PUBLIC ART TO MIXED USE AREA
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:
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
Sq. Ft Floor Area:
Valuation: $40000
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: 36903009.20080
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 F LAST CALLED INSPECTION.
indemnity 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
Issued by: Date:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE- ROOFS:
Signature Date
All roofs shall be inspected prior to any rooting material being installed. If a roof is
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
OWNER - BUILDER DECLARATION
Signature of Applicant: Date:
I 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)
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. 1 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 255 (a) should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self- insure for Worker's
material. Additionally, should I u equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by th Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance wit h u rtino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Se o 2 50 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:
rmit is issued.
A
rtify 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, 1
CONSTRU IO ENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, f 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
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. 1 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 m boned property for inspection purposes (We) agree to save
indemnify and ke harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expen ich may accrue against said City in consequence of the
1 understand my plans shall be used as public records,
granting of this mn. dditionally, the applicant understands and will comply
with all non- of t so rc egulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18. f
Signature Date Z/b
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • building cuperhno.org
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❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
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DESCRIPTION OF WORK
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE
TYPE
OCC.
SQ -FT.
VALUATION (5)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NETAREA
BATHROOM
REMODEL AREA
KITCHEN
REMODEL AREA
OTHER
REMODEL AREA
PORCH AREA tDECKAREA
TOTAL DECK/PORCH AREA
GARAGE AREA: LJDETACH
ATTACH
k DWELLING UNITS
ISA SECOND UNIT ❑YES
BEING ADDED? ❑NO
SECOND STORY []YES
ADDITION? [3NO
PRE - APPLICATION ❑YES IF YES. PROVIDE COPY OF
PLANNING APPL k []NO PLANNING APPROVAL. LETTER
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
ftUIVEDBY:
TO LI��.TION:
/r
By my signature below, 1 certify 0ea the following: I am the property owner or autho erty owner's behalf. I have read this
application and the information I ed is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatin i g onstruction. I authorize representatives of Cupertino to enter the above- identified roperty for inspection purposes.
Signature of Applicant/Agent _ _ Date.
SUPPLEMENT TION REQUIRED
New SFD Or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if any Hazardous Materials are being used as part of this project.
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER - THE - COUNTER
❑ EXPRESS
TANDARD
❑ LARGE
�] MAJOR
ILDING PLAN REVIEW
❑ NG PLAN REVIEW
❑ PUBLIC WORKS
❑ FIRE DEPT
❑ SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
B1dgApp 2011.doe revised 06/21/11
FM--7 CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
1AADDRESS:
20080 STEVENS CREEK BLVD
DATE: 01/16/2014
REVIEWED BY: COUNTER
MISC ITEMS
APN:
BP #: 14010089
"VALUATION: 1$40,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE:
0.0
PENTAMATION 1GENCOM
PERMIT TYPE:
WORK
INSTALL PUBLIC ART TO MIEXED USE AREA
SCOPE
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution I1 -053 Eff. 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes Q No
$0.00
2 hours Plan Check, Hourly
$278.00 1 STPLNCK
Suppl. PC Fee: (F) 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,0 Reg. Q OT
10.0-1
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
r.
E)
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee:
$0.00
hours Inspections
$278.00 1STINSP Inspection, Hourly
Strong; Motion Fee: 1BSEISMICO
$8.40
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$2.00
SUBTOTALS:'
$10.40
$556.00
TOTAL FEE: 1
$566.40
Revised: 01/15/2014