13010020 CITY Y OIF C>L P ER'I('>INO BUILDING PERMIT
BUILDING ADDRESS: 20030 STEVENS CREEK BLVD CONTRACTOR:; y PERMIT NO: 13010020
OWNER'S NAME: PREG BILTMORE DATE ISSUED:03/27/2013
OWNER'S PHONE: 6509313457 QrJ/)J� 6���D f� y Q� PHONENO �5�:�C'i:�����
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALD
License Class Lic.# DEMO FOR(lE)STRUCTURE R E 9359 SQ FT
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:
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:$10000
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 IT(EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating ��� �®����®�PERMIT ISSUANCE®�
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 IlD DIM((LAST CAILILIEI<D )II`1SlP TION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 9
granting of this permit. Additionally,the applicant understands and will comply ]Issued by: Dat /
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 11
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
➢hereby affirm that➢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)
1,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 t Bay Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with t ertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se�ti O5,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this 3 d
Owner or authorized agent: Date:
permit is issued.
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
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 expen s which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this it.Additionally,the applicant understands and will comply
with all no of s rce regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
M-0-1- 13
CITY 07 cCUPER RNR
FEE IESTRMATOR— BUILDING VISION
ADDRESS: 20030 scb DATE:11371-5 1REVIEWED BY:
A1P1�: ]B)P#: d QD *VALUATION:IOIV: $1 ,000
*]PERMIT TYO E: Demolition Permit PLAN CIIECK T)'PE.
PRIMARY )PEIVTAMATIOIV
USE: Commercial Building ]PERMITTXPEc 1COMMLDE M
WORK
SCOPE
FEE IID 1F]LR AREA
s.f.
1DEMOCOM 9,359
Afcech, Plan Check Plumb. Plan Chee Elec..Plan Check.
iLfi>Ch.Permil Fee Plumb. Permil Fee: Elec. Permit Fee.
Other,lfech.Imp. EJ Other Plumb Insp. Other Elee.Insp.
Me& /nsp.Fee: Plumb. /nsp. Pee: Elee.Insp. Fee:
(VOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works, Fire,Sanitary Sewer.District,School
District,etc.). Thesefees are based on the prelimWina information available and are onl an estimate. Contact the De t or addn'l info.
FLEE ITEMS (Fee Resolution 11-053 EIE 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
Plumb.11fech./Elec.
Permit Fee: $1,332.00
Suppl. Insp. Fee-0 Reg. 0 OT p 0 hrs $0.00
Phtmb./Mech./Flee
Pl1mb./.A1leeh.1Etee Permit Fee:
Construction .Tax:
A.dininistrative Fee:
PVork Without Permit?
Advanced Planning Fees:
Travel Documentation Fees:
Strom Motion Fee: IBSEISMICO $2.10 Select an Administrative Item
Bldg;Stds Commission Fee: . 1BCBSC $1.00
SUBTOTALS: $1,335.10 $0.00 TOTAL FEE; 1 $1,335.10
Revised: 10/01/2012