11110076 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10165 N DF AN%A BLVD. CONTRACTOR:S D DEACON CORP OF PERMIT NO: 11110076
CALIFORNIA
OWNER'S NAME: INFINITE LOOP I IO'fEL LLC 7745 GREENBACK LN STE 250 DATE ISSUED: 11/142011
ER'S PHON I?: 4086213094 CITRUS HEIGHTS,CA 95610 PHONE NO:(916)969.0900
CH LICENSED CONTRA(TOR'S DECLARATION - r rn rl
�11 'BUILDING PERMIT INFO: BLDG "' - ELECT - PLUMB
License Class ? Lic.d_ 760 y7e
r r r
Contractor Date liliq
MECH RESIDENTIAL COMMERCIAL
I hereby affirm that 1 nm licensed under the provisio of Chapter9 JOB DESCRIPTION:CUPERTINO HOTEL-INSTALL TEMP POWER POLE
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of prr)ury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided Ibr by Section 3700 ol'Ihe Labor Code,for the
performance of the wutk for which this permit is issued. Sq.FI Floor Area: Valuation:$200
1 have and will mainain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perlL mmncc of the work for which this
permit is issued. APN Number:32634057.00 Occupancy Type:
\I'I'LIC,\N'I'Ciilfl'I FICATION
I certify that I have read this application and smtc Ihnt the above information is
correct.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorise representatives of this city to enter
upon the above mentioned property fir inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City Of Cupcnino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionnly,the applicant understands and will comply
with all non-point sourer rcgrdatints per the Cupertino Municipal Code,Section Issued (-
9.18.
Signatur Date I V*(
RE-ROOFS:
Oa',CF.It-Ii1111.Dlilt lH?C.LAIL1'I'ION All roofs shall be inspected prior to any roofing material being installed.If roof is
installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm itrI ani rxi•mpt from Ibr Contractor's License Law for one of
the following M'u rr;unns: inspection.
I,as owner of the property,or my employees k, th wages as their sole compensation, Signature of Applicant: Date:
will do the work,;red the structure is 1101 intended or offered for sale(Sec.7044,
Business&Professions Code)
1,0 owner of the property,sin exclusively cumrating with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sce.7044,Business& Piohssions Code).
hereby affirm under,penalty of perjure one it the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Cenilienle ol'C'onscnt to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain -
Compensation,as provided fur by Scclion 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this pe:mil is issued. Safety Code,Section 25532(x)should I store or handle hazardous material.
I have and will mainti n Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of the Loboi Code,for the prrl'urnru ec of the work for which this contaminants as dented by the Bay Area Air Quality Management District I will
permit is issued
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the perlhnnance of the 0rn9: I'nnchich this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in tiny mmtncr so as w become subject to the Worker's O ner aulhor'
Compensation Imes of C,difurnia. 11;idlcr making Otis certificate of exemption,l Date: /[ ��
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply,vilh such provisions or this pcnnil shall be deemed revoked. - CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICAN"IC'P:RTIFICATION for which this permit is issued(See.3097,Civ C.)
I certify that I have read this application and,nuc that the above information is Lender's Name
correct.1 agree to comply,eith all city tmd emimy ordinances and state laws relating
to building constmnion.and herebyauthnd>c rcpresanatives of this city to enter Lender's Address
upon the above mentioned property Ibr inspecion purposes.(We)agree to save
0 nify and keep hannlesc the C'ac o(Cupetlino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses,which may accrue a;;ainsn.said City in consequence of the
6..,.ung of this pennii.Additionally,the applicant understands and will comply I understand my plansshall be used as public records.
with all non-point source regulatints per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
• CITY OF CUPERTINO
6 ITEMS OF 6 - PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32634057. 00
DATE ISSUED. . . . . . . : 11/14/2011
RECEIPT #. . . . . . . . . : BS0000IS307
REFERENCE ID # . . . : 11110076
SITE ADDRESS . . . . . : 10165 N DE ANZA BLVD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : INFINITE LOOP HOTEL LLC
ADDRESS . . . . . . . . . . : 20660 STEVENS CREEK BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2218
RECEIVED FROM . . . . : SD DEACON CORP OF C
CONTRACTOR . . . . . . . : RICHARD G SMITH LIC # 25530
COMPANY . . . . . . . . . . : S D DEACON CORP OF CALIFORNIA
ADDRESS . . . . . . . . . . : 7745 GREENBACK LN STE 250
Ci'i'Y/STATE/ZIP . . . : CITRUS HEIGHTS, CA 95610
TELEPHONE . . . . . . . . : (916) 969-0900
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1 .00 41. 00 0. 00 41 .00 0 .00
1BCBSC VALUATION 200 .00 1. 00 0. 00 1. 00 0. 00
1BSEISMICO VALUATION 200.00 0. 50 0. 00 0 .50 0. 00
1EPERMITFE FLAT RATE 1 .00 44 . 00 0. 00 44 . 00 0. 00
IERT<200 UNITS 1 .00 44 . 00 0. 00 44 .00 0. 00
1TRAVDOC FLAT RATE 1 .00 44 .00 0. 00 44 .00 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 174 .50 0. 00 174 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 174 .50 VISA
---------------
TOTAL RECEIPT 174 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER
IIIIC�)� �0
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
•CUPERTINO (408)777-3228• FAX(408)777-3333• buildinp(acuoertino.om M I S
PLUMBING MECHANICAL CIRICAL OmmamLANEous
PROJECT ADDROSf' y/`5 /1),7>e_ �� (y �M -3 �� 3
OWNER NAF@ J/ L GGC PRlb o lOZ a q EMAM
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME PRONE
STAEETADDRESS CITY,STATE, Z@ FAX
13OwNm 13OWNERDER 12-BImOWNERA= W c�CONTRACIOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGONsMt ❑ OEVEIMPER ❑TENANT
CONTRACTOR NAME ,D••�llk�V h LICENSE N!4F__ LICENSE BUS.LIC 0
COMPANY NAME5--D. ` Cm H MAEM- ^ PAX
STREET ADDRESS 4/16 WW
CITY,STAT$Z8 FHONE
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NAME LICENSE NUMBER BUS.LIC
COMPANYNAF®' FAX
STREET AD CITY,STATE,ZIP
OF ❑SFDcr DUPLEX ❑ MM71-FAMMY PROJECT IN WIIDLANO ❑ YES PROJECTIN ❑YES IS THE SLOG ANq❑�Y'ES'
BUDDING: COMMERcs L ORGAN INTERFACE AREA NO FLOOD ZONE NO EICHIM HOMET oy.0
DESCRIPTION OF WORK '
v ei
TOTAL VALUATION: �0 v OV RECEIVED BY: 75
J .
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf I have read this
application and the information I have provided is correct have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and spun laws relating to buildin construction. I rept =o=wes of Cupertino to enter the above-ideadfled property for inspection pu@oses.
Slgnu'uraofApp]1cw 4 Date:
SUPPE22AECNTAL 24FORMATION REQUIRED r
OFF1,GZ USE ONLY
u OVER-TEB-COUNTER
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❑ MAJOR
,: MPPAdreApp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
• ADDRESS: 10165 n. de anza blvd. DATE: 11/14/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $200
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP14
USE: PERMIT TYPE:
WORK install temp power pole
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 . 100 Amps $44
TOTALS: $44.00
d te'Jr r"laq C:h [k P/1iu11), Plan C4vck Elec.Plan Check 1 0.0 1 hrs $0.00
:bleak Perron Fee Fund,, ,"nrnul Fee,: Elec.Permit Fee: IEPERMIT
• Omer ileci.In.}p. nber Phaah br..p. Other Elec. Insp. 0.0 hrs $44.00
.Vz rl:.)nsp. Fee: Pluurb. Gasp.Nee: Eley,Ins?. Fee:
N07'E: This estimate does not include fees due to otter Departments(le.Planning,Public Works,Fire,Sanitary Sewer District,School
Worirt,ere.). Thesefees are based on the relinina information available and are only an esdmate. Contact the Dept for addn'l infa
FEE, ITEMS P'ee Resohdion 11-053 EN 7/1/11) FEE QTY/FEE MISC ITEMS
Piro Check ck(ire:
SI(ppl, PC Fee
PMC Plan Check: $0.00
Pcrmii P'ce:
Supp1, Lisp
PMC Unit Fee: $44.00
PMC Permit Fee: $44.00
C'rnarlrrmtiorr '1'icc
Administrative Fee: ]ADMIN $41.00
Work Without Permit? C) Yes Q No $0.00
iva:x-1111nnnin�;l"c"S:
Travcl Documentation Fee: ITRAVDOC $44.00
Shone Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Cilde Su1s Commission Fee: tBCBSC $1.00
SUBTOTALS: $174.50 $0.00 TOTAL FEE: $174.50
Revised: 10/01/2011