11110098r - • CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 3 RESULTS WAY
CONTRACTOR:'
tPERMITT NO. 11110098
OWNER'S NAME: EC[ TWO RESULTS LLC I (11 j" Ujg�_JG PfJV I Utl(IW Iy 1 I DATE ISSUED: 11/172011 I
(aj&JER'S PHONE: 6502924100 P"), Ur( ( U fd+5 I PHONE NO: I
License Class ,4 _# t't C-2/Lic. N 0 O % i
Contmctocop%? 44* hrlr/(rado eA Bate e d� — 41
1 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.
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 1 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.
Date I( -11 -t -I
• 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
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,
AM and expenses which may accrue against said City in consequence of the
9ng of this permit. Additionally, the applicant understands and will comply
s .; ell non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Date
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r,
MECH r RESIDENTIAL F-1 COMMERCIAL r
JOB DESCRIPTION: APPLE- PARAPAT REMOVAL; NON-STRUCTURAL
Sq. Ft Floor Area: I Valuation: $12550
APN Number: 35720042.3 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:___,Date://1/;7"4
RE -ROOFS:
All roofs shall be inspected prior to any roofing material behg 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 the
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(x) should I store or handle hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Ounlity Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
authorized a ant:
Date: 1147-1)
CONSTRUCTION LENDING AGENCY
1 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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
•
CITY OF CUPERTINO
2 ITEMS OF 5 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Elk: Lot:
APN ........: 35720042.3
DATE ISSUED.......: 11/17/2011
RECEIPT #.........: BS000015339
REFERENCE ID # ...: 11110098
SITE ADDRESS .....: 3 RESULTS WAY
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: ECI TWO RESULTS LLC
ADDRESS ..........: 1301 SHOREWAY RD STE 250
CITY/STATE/ZIP ...: BELMONT, CA 94002
OPERATOR: patg
COPY # : 1
RECEIVED FROM ....: COMPLETE DECON, INC
CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096
COMPANY'..........: TBD - TO BE DETERMINED
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
FEE ID UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
---------- -------------
1BCBSC VALUATION
----------
12,550.00
----------
1.00
----------
0.00
----------
1.00
----------
0.00
1DEMOCOM SQ FEET
0.00
523.00
0.00
523.00
0.00
TOTAL PERMIT
----------
524.00
----------
0.00
----------
524.00
----------
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
1,050.64
---------------
1,050.64
VOICE ID DESCRIPTION
-------- ----------------------------
704 DEMO
REFERENCE NUMBER
--------------------
#17076
VOICE ID DESCRIPTION
-------- ----------------------------
m
PL
CONSTRUCTION PERMIT APPLICATION PLOT
CHECKED
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION Ir 1 7
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 DA
(408) 777-3228 • FAX (4KAITuR
3333 • building(a),cuoertno.om
PLAN" I
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PROLE DRFSS
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0 OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CO CTOR Nr,�,MF�j, SE ER
CE/N�SE TYPE
BUS. LICa -! -
COW ANY NAMEE-MAIL
_
PAX
07 71/7 Y'ISLL
ADDRESS C
. gTA7 ZIP
PHONE
690 690 L; SCcoetd V1� 3
610. C d
707. %' OO
ARCM TECVENOINEER NAME
LICENSE NUMBER
BUS. LIC N
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE LIP
PHONE
DESCRIPTION OF WORK Fq
W01% r w
EXIST24G USE
PROPOSED USE
CONSTIL PE
NSTOomc
OI iLt%
D,C r. I
2.
use
TYPE
OCC.
SQ IT
VALUATION(S)
EXISTO
AREA
NEW FLOOR
AREA
DEMO TorAL .,//•,
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BATHROOM KITCHEN OTHER
REMODELARRA REMODELAREA REMODELAREA
PORCHAAEA DECK AREA TOTAL DECTGPORCH AAEA GARAGE AREA: DETACH
ATTACH
N DWELLMG UNITS;
ISASECONDUNIT YES
MCONDSTORY YES
BEING ADDEDT aNO
ADDMON'T BNB
PRE -APPLICATION ❑YES T YES, PROVIDE COPYOF
PLANNRJGAPPLN NO PLANNINGAPPROVAL LETTER
❑
IS TDE BLDG AN ❑YES
BICBLER BOMB? E5-NO71
RECEIVED BY: /
TOTALVALUA
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By my signature below, I certify to each of the following: r am the property owner or authorized agent to act on the prnpetty owner's behalf. I hie read this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize repmmmtives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applica t/AgenO Date: el
SUPPLEMENTAL INF RMATIONREQUIRED
PI.ANC'EECKTYPE
ROUTING SLEP
New SFD or Multifamily dwellings: Apply for demolition permit forygx
building(s). Demolition permit is required prior to issuance of building
Tm�cooNrEx
m
Bu¢D PLAN REVIEW
permit for new building.
❑ E,X'FRM
PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project
❑ LARGE
❑ Fina bEFT
Copy of Planning Approval Letter or Meeting with Planning prior to
Mittal of Building Permit application.
❑ MAJOR
sAxrrnRY saweR DLsrRICr
❑ ENVIRONMaNTALBEALTH.
BldgApp_2011.doc revised 06/21/11
24oy-7
•
•
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CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
imADDRESS:
3 results way DATE: 11/17/2011
APN: BPk:
REVIEWED BV: bobs.
*VALUATION: $12,550
°PERMITTVPE: Demolition Permit
Atech. Perurit Fee:
PLAN CHECK TYPE.
PRIMARY Commercial Building
USE:
00jer tPolt. Asp,
PENTAMATION 1COMMLDEM
PERMIT TYPE:
WORK
ara at removal non structural
Pluurb. fnvp. Fee:
SCOPE
Permit Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the oreliminary informatlon available and are oniv an estimate. Contact the Dent for addn'I info.
FEE ITEMS (Pee Resolution 11-053 E . 711/11)
.t fedi. Pica Check
Plumb_ Plan C&,�:k
Blee. Plan Check
Atech. Perurit Fee:
Piond:. Permit Fi:e:1Zltc.
Pern;h Fee:
00jer tPolt. Asp,
U1he. Plumb hasp.
Ofher Ah, -c. Drrp.
Afe h. fmpy Fee:
Pluurb. fnvp. Fee:
file,=. Inq>. Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the oreliminary informatlon available and are oniv an estimate. Contact the Dent for addn'I info.
FEE ITEMS (Pee Resolution 11-053 E . 711/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC ,Fee
f'llunb,%ider:h.akc
Permit Fee:
$523.00
Suppl. Insp. Fee:Q Reg. Q OT0,0
hrs
$0.00
F'fumb.;'h/ech.:1 lec
Plumh.;;ble clr./fSlax Permit Fera•
Construction Tac
Adminis7 alive Fee.:
JT;rrk It'ithout Pormil?
Advarwad Plannin,-, Peev:
Travel DocumeniQlLon fres:
Strove Motion Fee: IBSEISMiCO
$2.64
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $526.641
$0.001 TOTAL'FEE:'
$526.64
Revised: 10/01/2011
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CUPERTINO
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-9255
Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS:
2r"s k
)
BUSINESS NAME, ,
PERMIT #
OWNER'S NAME: C l
R Ap. I u _
Cabinets & Millwork
PHONE # 70-7 7'17 - -?0 v
GENERAL CONTRACTOR:
BUSINESS LICENSE #
ADDRESS: NG yJ /i Soc
,( s' nn. .1 % e
f Mo
CITY/ZIPCODE:2 Pn. c i ySi U
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
'e
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF' CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
✓
SUBCONTRACTOR
BUSINESS NAME, ,
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping.
Lathing
Masonry
Painting / Wallpaper
Paving
r
Plastering
� .� moi=. //
Plumbing'
Roofing i l
Septic Tank
Sheet Metal
Sheet,Rock.
Tile _
Owner / Contractor Signature
Date