13020108 UTY OF CU?ERTINO BUILDING PERMIT
BUILDING ADDRESS: 20400 STEVENS CREEK BLVD CONTRACTOF PERMIT NO: 13020108
OWNER'S NAME: CUPERTINO CITY CENTER BUILDINGS DATE ISSUED:02/20/2013
OWNER'S PHONE: 4086602825 PHONE NO:
10, LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL
License Class Lia!t 7SZ'1 3A **SUITE 150**DEMO(E)WALL(10'6"), INSTALL(N)
PARTITION WALL TO CREATE 4 CUBICLE SPACES
Contracto � /" �� f(. �� id$1Si Date
't
hereby affirm that I am lie en ed and r t e 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
performance of the work for which this permit is issued. Sq.Ft Floor Area; Valuation:$1500
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 APN Number:36901028.00 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 180 DAYS OF PERMIT ISSUANCE OR
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 FRO 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
granting of this permit, Additionally,the applicant understands and will comply Iss
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.
❑ ER-BUILDFR DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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
California health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 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
1 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 1
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 nd 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent; Date: 33
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 CONST TION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must 1 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 1 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, ARCHITECT'S DECLARATION
costs,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 CU PIEIEZTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 20400 STEVENS CREEK BLVD DATE: 02/20/2013 REVIEWED BY: MELISSA
APN: 369 01 028 BP#: 'VALUATION: $1,500
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION 1 B TI
USE: PERMIT TYPE:
WORK DEMO E WALL 10'6" INSTALL N PARTITION WALL TO CREATE 4 CUBICLE SPACES
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
B (Tenant Improvements) II-B,111-B,Iv,v-B $0.00 $0.00
TOTALS: 0 $0.00 $0.00
MIECH,HOURLY 0 Yes E) No PLUMB,HOURLY Q Yes Q No ELEC,HOURLY Q Yes Q No
Xlech. Plan Check Plumb.Plan Check Elec.Plat Check7j�
FA—,,c/?.Permit Fee: Phimh. Permit Fee: Flec,Permit Fec:
Other•Afech. Imp. Li Other Plumh lnsp. Li I Other F,lec, Insp. ET
Mech.Insp. Fe Plumb. hasp. Fee: Elec. Insp.Fee:
NOTE: This estimate does not include fees due to other Departments(i.4 Planning,Public Works,Fire,Sanitary Sewer District,School
Districtetc). These ees are based on the relimina information available and are onl an estimates Contact the De t or addn I info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 10 Lf. Interior Partitions
Suppl. PC Fee: (E) Reg. Q OT 1.0 1 hrs $133.00 $467.00 1PARTICOMM
PME Plan Check: ISUPPKFEE $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. ® OT 0,0 firs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Conswuc lion Tax:
Administrative Fee:
Work Without Permit? O Yes (E) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential Q
Travel Documentation Fees: Building or Structure Q
Stronp, Motion Fee: IBSEISAflCO $0.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $134.50 $467.00 'TOTAL FEE: $601.50
Revised: 01/01/2013