13060203 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20030 STEVENS CREEK BLVD CONTRACTOR:J014NSTONE MOYER, PERMIT NO: 13060203
INC.
OWNER'S NAME: PREG BILTMORE 1720 S AMPHLETT BLVD STE 250 DATE ISSUED:06/25/2013
OWNER'S PHONE: 6509313400 SAN MATEO,CA 94402 PHONE NO:(650)570-6161
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11COMMERCIAL❑
License Classes Lic.# _Z • 1
` INSTALL(N)TEMPORARY TRAILER FOR
CONSTRUCTION
Contractor YA
t {sa iPN%t% "Date T F PERSONEL
I hereby affirm that I am licensed carder the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions 7 J
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$6500
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:36903004.00 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 P T 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 FASIT- ALLED 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 =Date:
with all non-poi�ftource reg}t tions per the Cupertino Municipal Code,Section "
9.18. !
- RE-ROOFS:
Signature Dat r - All roofs shall be inspected prior to any roofing material being installed.If a roof is
f.` 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
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(x)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 th Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti n$25505 /25533,and 25534.
Section 3700 of the Labor Code,for the
performance of the work for which this _;` / '" t
p Owner or authorized agent: r Date .
permit is issued. f '
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,l 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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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 CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
jTADDRESS: 20030 STEVENS CREEK BLVD DATE: 06/25/2013 REVIEWED BY: MELISSA
I
PN: 369 03 004 BP#: 1230 to aG ' *VALUATION: 1$6,500 j
,'PERMIT TYPE: Building Permit =:F PLAN CHECK TYPE: Alteration/Addition/ Repair
Commercial Building PENTAMATION
PRIMARY
USE: g PERMIT TYPE: 1 GENCO
WORK INSTALL N TEMPORARY TRAILER FOR CONSTRUCTION PERSONEL
i
SCOPEI
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i
Xlech, Plan Cheep plumb. Plan Check Elea.Ph 'hcch
:Wech. permit Fee: Plumb. PConit Fee: Elce. Permit Fee.,
011tei Agee h, has7z Other plumb h7slr. Other Elec.Insp.
A'Ieck Insp. Fee: Phnnb. hisp. Fee: Elec.Insp,Fee:
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 prelintina information available and are onl an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 L J hours Plan Check,Hourly
Suppl.PC Fee: Q Reg. Q OT 1 0.0 1 hrs $0.00 $133.00 ISTPLNCK
PME Plan Check: $0.00
Permit Fee: Hourly Only? Q Yes Q No $0.00
Suppl. Insp.Fee:Q Reg. Q OT 0,0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax: _TT
lcliniaiswalive Fere: 0
Work Without Permit? Yes Q No $0.00
Advanced Planning Fee: $0.00 hours Inspections
Tr(wel Doctniierthition Fee,y- $133.00 ISTINSP Inspection,Hourly �A
Strong Motion Fee: IBSEISMICO $1.37 Select an Administrative Item.
i
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $2.371 $266.00 TOTAL FEE. F $268.37
b Revised: 04/29/2013
i