12080017CITY OF CUPERTINO BUILDING PERMIT
--
BUILDINGADDRESS: 19200STEVENSCREEKBI-VD
CONI'RACI'OR:' . PERM ITNO: 12080017
! H 1 �- `- DATE ISSUED: 08I06R012
O\YNEMSNAMIi: CYPRESS BUILDING ASSOC ETAL
OWNER'S PHONE.: 6504248383
I (-y— �Pu
PUONENO:
❑ LICENSED CON"fRACI'OR'S DECLARATION
r
r PLUMB r
13UILDING PERMIT INFO: BLDG ELECT
License Class Lie. 01r
r_ r
Conimctoi Date -`
�IECH RESIDENTIAL COMi111E12CLV.
hereby affcrn that I out licensed under the provisions of Chapter 9
JOB DESCRIPTION: SITE ACCESSIBILITY UPGRADE
(coal menci ng is its Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force :lad effect.
hereby affirm under penalty of perjuy one of the fulliming Iwo 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
perleormance of the work for which this permit is issued.
Sy. Ft Flour Area:
Valuation: $60000
I have and Will maintain Worker's Compensation Insurance, as provided for by
:is
Section 3700 of the Labor Code, for the performance of die work for which th
permit is issued.
.\I �\ Number: 37506005.00
occupancyType:
\I'I'LIC,\N'I' Clilffll�IC,\'PION
I certify that I have read this application and state that the above infornmation is
correct. I agree to comply with all city and county ordinances and state Imes relating
to building construction,:md hereby authorize representatives ofthis city to enter
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indemnity and keep harmless the 6tyofCupertino against liabilities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
1811.DA.YS FROM LAST CALLED INSPECTION.
gnumting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
A n'
9.18.
Issued by: / Date:
Signature Dale
Q
v
❑ O\VN'Elt-I UILDEIR DECLARATION
RE - ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
hereby affirm that I an) exempt from the Contractor's License Law fur one of
installed without first obtaining an inspection, I agree to remove all new materials for
the following two reasons:
inspection.
I, as owner of the property, or any employees With wages as their sole conmponsalion,
will do the work, mid the structure is not intended or offered for sale (Sec.7044,
Signmurc of Applicant: Date:
Business B Professions Code)
1. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR RE FfF;R
IL\"/-ARDOIIS MATERIALS DISCLOSURE
hereby affirnn under penalty of perjury one of the following till ee
declarations:
I have laid will maintain a Certificate ofConsent to self -insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the labor Code, for the
California I Iealth S Safety Code, Sections 25505. 25533. and 25534. 1 will maintain
performance of the Work for which this perm Is Issued.
compliance s, ills the Cupertino Municipal Code, Chapter 9.12 and the Health J
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(a) should I store or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
Additionally, should I use equipment or devices which emit hazardous air
c0ntaminaius as defined by the Bay Area Air Quality Management District 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
I certify that in the performance of the Work for which this permit is issued, I shall
Health A` Safety Cade. Sections 25505. 25533. and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation Imes of Cali foria. ll', after making this certificate of exemption,I
Owner or authorized agent ���,,, �r�
become subject to the Worker's Compensation provisions of the Labor Code, I musl
�� Date:_.7y/L
�r f
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTI FICATION
I hereby affirn that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is
for which this pemnit is issued (Sec. 3097, Cis, C.)
correct. I agree to comply with all city and county ordinances mid state laws relating
Lender's Name
to building construction, land hereby authorize representatives of this city 10 enter
upon the above mentioned property for inspection purposes. (We) agree to sate
Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
ARCI I ITECI"S DECLARATION
granting of this permil. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
I undershmd my plans shall be used as public records.
9.19.
Licensed Professional
Signature Date
Revised: 07/01/2012
CITY OF CUPERTINO
RM—ft FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 19200 STEVENS CREEK
DATE: 08/06/2012
REVIEWED BY: LARRY S
APN:
BP#: 12080017
*VALUATION: 1$60,OOQ
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
USE: Commercial Building
PENTAMATION
PERMIT TYPE: 1GENC0
WORK I
SITE ACCESSIBILITY UPGRADES
SCOPE
ltech. Plan (71"!ci
Phwd)' Plan Chcrc'G
T'Jei% Pl'w Check,
Poch, Perwil Fec>,-
Pltut3h. Vomit F"c'
L7c'c. po wit
C')thtr ;11� cTr. lnsp.
C /ho-1,11wib hispEI—L—
C_ dw Flax. Lisp. Ll
�11ach' Cusp. Fec;
I Phmib. hrsp. I er:
Elc'c. Insp, Fec .
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 preliminar information available and are ontv an estimate. Contact the Dept for addn'l in o.
FEE ITEMS (Fee Resolution 11-053 Ef. 7/1/11Z
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes No
$0.00
0 hours Plan Check, Hourly
$133,00 1STPLNCK
i
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:O Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Constrticfion Tttx.
clrlai.rtLsr`ratr i e Fec .
0
0
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning Fee:
$0.00
® hours Inspections
$532.00 ISTINSP Inspection, Hourly
0
0
Tr�lfv<>! Docrnnentrl7icu� Frei:
Strong Motion Fee: IBSEISMICO
$12.60
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$3.00
SUBTOTALS:
1 $15.601
$665.00
TOTAL FEE:
$680.60
Revised: 07/01 /2012