11090106CITY OF CUPERT1,40 BUILDING PERMIT
BUILDING ADDRESS: 10120 N DE ANZA BLVD
CONTRACTOR: SPC CONTRACTORS,
PERMIT NO: 11090106
INC.
" vNER'S NAME: ROMAN CATHOLIC WELFARE CORP OF SAN
859 SAVAKER ST
DATE ISSUED: 09/16/2011
., NER'S PHONE: 2526441
SAN JOSE, CA 95126
PHONE NO: (408) 298-5759
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic. #
TEMP GENERATOR AT COMMERCIAL PROPERTY FOR 3
DAY
Contractor Date
FESTIVAL
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:
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: $3000
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: 31626097.00
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 0 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 DAY OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
'
costs, and expenses which may accrue against said City in consequence of the
7,0
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 roofing material being installed. If a roof is
installed without first obtaining an inspection, I 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)
I, 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
E7,
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 I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's
material. Additionally, should I use equipment 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 Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner � Date:,?—
permit is issued.
or authorized agent: o/\.ver
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
CONSTRUCTION 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
APPLICANT CERTIFICATION
Lender's Address
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
-n the above mentioned property for inspection purposes. (We) agree to save
.nnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
L.,.,ts, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
"'
Signature.. Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 10120 n. de anza blvd
DATE: 09/13/2011
REVIEWED BY: bobs.
UNITS
APN:
BP#:
"VALUATION: 1$3,000
PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 REAP8
I PERMIT TYPE:
WORK
temp generator at commercial property for 3 day festival use.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Other Power Devices
1BREMPOWER
1
#
$163
PME Unit Fee:
$163.00
PME Permit Fee:
$44.00
Administrative Fee: ]ADMIN
$41.00
Work Without Permit? 0 Yes (j) No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRA VDOC
$163.00
Strom Motion Fee: IBSEISMICR
NOTE. This estimate does not include fees due to other Depts (i.e. Public Works, Sanitary Sewer District, School District, etc.).
These fees are hated on the nrelindnary information available and are onlv an estimate. Contact the Devt for addn'1 info.
FEE ITEMS (Fee Resohition 11-053 E/.' 7;'11)
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee:
$163.00
PME Permit Fee:
$44.00
Administrative Fee: ]ADMIN
$41.00
Work Without Permit? 0 Yes (j) No
$0.00
A
Travel Documentation Fee: ITRA VDOC
$44.00
Strom Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$293.50
$0.00J TOTAL FEE:
$293.50
Revised: 09/02/2011
CUPERTINO
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GENERAL PERMIT APPLICATION "W"D In
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COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIjj jj ��
10300 TORRE AVENUE • CUPERTINO, CA 950143255 s�
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(408) 777-3228 •FAX (408) 777-3333 •building a(�cupertino.orq ,NMNG fl � � `�
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CONTRACTOR NAME �l
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USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMILYPROJECT
BUILDING: ❑ COMMERCIAL
IN WILDLAND ❑ YES
TURBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
IS THE BLDG AN El YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION:3
RECEIVED BY:
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By my signature below, I certify to each of the following: 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 have provided is correct. 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 to building construction. I authorize representatives of Cupertino to enter the above-identifiedproperty for inspection pu(poses.
Signature of Applicant/Agent: ,/�-1� zDate: v —'
c.TL CSUPPLEMENTAL INFORMATION REQUIRED
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MEPMiscApp_2011.doc revised 06121111
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CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - building5cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN
BP#
OWNER NAME OWNER A DRESS
h e - a r _ C�
DESCRIPTION OF WORK:
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
14_1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
��2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I"may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
�
name instead of my own.
✓j
/'� 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
ll5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
M. I understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
M7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
M8.'l understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
014WerBuilderForin 2010.doc revised 04114110