12030049CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10218 S TANTAU AVE CONTRACTOR: PROVISION PERMIT NO: 12030049
DEVELOPMENT, INC.
OWNER'S NAME: VIRAY PROPERTIES LLC 1288 FIFER RD STE 207 DATE ISSUED: 03/09/2012
OWNER'S PHONE: 4087687832 SUNNYVALE, CA 94086 PHONE NO: (408) 245-099t
® LICENSED CONTRACTOR'S DECLARATION
License Class- I Lie. t# 8'7 IF `3 ! /
Contractor 1 I f�AF1 dC F' I a t'-vL i E YdC'v to l q
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 (tic 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 (his 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 a€€d 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-poir€t source regulations per the Cupertino Municipal Code, Section
9.18.
i
Signatures----°... � -�--_�.. � Date
® OWNER -BUILDER DECLARATION
I hereby affirm that I a€n exempt front 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, an€ exclusively contracting with licensed contractors to
construct the project (See.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,
€ 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
forthwith comply with such provisions or this permit shall be deemed revoked.
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.
BUILDING PERMIT INFO: BLDG 1...: ELECT I__. PLUMB 1
MECII 1 RESIDENTIAL 1 COMMERCIAL �
JOB DESCRIPTION: DEMO EXISITNG 1858 SF SFDWL, ONE-STORY
Sq. Ft Floor Area: i Valuation: $8000
APN Number: 37507032.00 6 Occupancy Type:
PERMITy = NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
a DAYS FROM
Issued4kkF
RE -ROOFS:
All roofs shall be inspected prior to any rooting material beiig installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of tile
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
€naintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner ar auth�rtze�a�e€tt: f -
_ ? Date: > 2
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of Nuxk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Date.
CITY OF CUPERTINO D
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10218 S. Tantau DATE: 03/0912012 REVIEWED BY: jsg
APN -,I �gft, D BP WALUATION: 1$8,000
PERMIT TYPE: Demolition Permit
NOTE. This estinutte does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitaty Semler District, School
District, etc.). These fees tire based on the prelininaty iiifornutdon available and tire ono) an estintale. Contact the DgLY.Lor etildn 'I in
FEE ITEMS (Fee -,1?e,sohejo,,l 11-053 Err 7,11,11) FEE QTY/FEE MISC ITEMS
Permit Fee: $523.00
Suppl. Insp. Fee.0 Reg, Q OT Q Q hrs $0.00
A
strofw motiorl IBSEISMCR $0.80 Select an Administrative Item
Bldg l,4dq-CcyLLnd,,isjon Fee, IBCBSC $1.00
rSUBTOTALS: $524.80 $0.001 TOTAL
Revised: 1/19/2012