12020055CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20245 STEVENS CREEK BLVD
OWNER'S NAME:
I SAN JOSE, CA 95122 1 PHONE NO: (408)280-1666 1
❑ LICENSED CONTRACTOR'S DECLARATION
License Class
Contractor t) 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 carder 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.
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
permit is issued.
APPLICANT CERTIFICATION
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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18. ,,
.„
SignatureDate
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Ad
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20245 stvns cek blvd. DATE: 02/1312012 REA71EWED BY: bobs.
'51
*'VALUATION: F$92,250
APN: BP#�
PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building ENTANIATION FURN/AC
USE: PERMIT TYPE:
.. WORK-. install new roofmounted HVAC units total of
SCOPE I
Mech, Platy Check 1 0.0 [hrs $0.00
Mech. Permit Fee: IMPER141T
Other Mech. Insp. Ehrs
l L—J
NOTE: This eNdruatedoes not include fees flue to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Dh,f-W vfn 1 Th— f— ftN1D haead no, tho blinr"Itaymp "Imilahlo fypidar,, nook aij ,vYi"oah,- Cmaaet tho Dent Mraddull into.
FEE ITEMS (Fee J?qsolujo�i 11-053 �VPI I
FEE
QTY/FEEF
MISC ITEMS
PME Plan Check:
$0.00
F-1
PME Unit Fee:
$1,430.00
PME Permit Fee:
$44.00
Administrative Fee: IADAffN
$41.00
Work Without Permit? 0 Yes 0 No
$0.00
A
Travel Documentation Fee: I TRA 11DOC
$44.00
stroll'(1motion rce; IBSEISWCO
$19.37
Select an Administrative Item
Bldg,,',tdg Commission Fee IBCBSC
$4.00
SUBTOTALS:
$1,582.37
$0.00j
TO--
$1,582.37
Revised: 1/19/2012