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11110097 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 5 RESULTS WAY CONTRACTORERMIT NO: 11110097 OWNER'S NAME: ECI TWO RESULTS LLC [ -0JVjfJ&1yLMJ DATE ISSUED: II/172011 ER'S PHONE: 6502924100 Lf>lLJ)'-rI ,5- PHONE NO: LICENSED CONTRACTOR'S DECLARATION r r f� BUILDING PERMIT INFO: BLDG r- ELECT PLUMB License ClassA-MAL C-14 Lic.p f O O Z 4k r r r MECH RESIDENTIAL COMMERCIAL Contractor(*,,'11e14 CAVI�u1� Date �� 1 hereby affirm hat 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APPLE-PARAPAT REMOVAL;NON STRUCTURAL (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 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 Sq.Ft Floor Area: Valuation:$12550 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35720041.5 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. 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. Issued by: - Date: Signaturel t� n. Date 1//7-11 • OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,m provided for by Safety Code,Section 25532(x)should I stare or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined 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 performance of the work for which this permit is issued,l shall Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner o•authorized a t: �,, become subject to the Worker's Compensation provisions of the Labor Code,1 mus[ Date: //�f /.i/l forthwith comply with such provisions or this permit shall be deemed revoked. '-T7�-7� CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's 1 certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, iftand expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION Wg of this permit.Additionally,the applicant understands and will comply IN all non-point source regulations per the Cupertino Municipal Code,Section 1 understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 3 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35720041.5 DATE ISSUED. . . . . . . : 11/17/2011 RECEIPT #. . . . . . . . . : BS000015339 REFERENCE ID # . . . : 11110097 SITE ADDRESS . . . . . : 5 RESULTS WAY SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : ECI TWO RESULTS LLC ADDRESS . . . . . . . . . . : 1301 SHOREWAY RD STE 250 CITY/STATE/ZIP . . . : BELMONT, CA 94002 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 1BSEISMICO VALUATION 12, 550.00 2 .64 0 . 00 2 .64 0. 00 1DEMOCOM SQ FEET 0.00 523 . 00 0. 00 523 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 526.64 0.00 526.64 0.00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO • CITY OF CUPERTINO D FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 5 results way DATE: 11/17/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $12,550 *PERMIT TYPE: Demolition Permit MAN CIl£fCK TWE. PRIMARY Commercial Building PENTAMATION 1COMMLDEM USE: PERMIT TYPE: WORK ara at removal non structural SCOPE FEE ID FLR AREA s.f. 1DEMOCOM 1 Meek Phar Cheek Pluwh, Plan Check liicc.Pliru Chcc/r hlra:Yr. Peruiir Pu. /'fund?.Pernfil?Yoe: Eh•c. Parmh f ee: • Olher,Vr,-ii./rap. Olttei.plamh hup. Other Eiar.. bup. :tied?.lnvp Fere Pluod:. bays,Pia'; r,Yer.lnvp Feer NOTE: This estimate does not Include fees due to other Departments(Le.Planning,Pubic Works, Fire,Sanitary Sewer District,School District eta). These fees are based on the prelindna In ormation available and are only an estimate. Contact the Dept foraddn7Info. FEE ITEMS Lfee Resolution 11-059 EB" 2/l/I U FEE QTY/FEE MISC ITEMS Pian Check F(c: Suppl. PCI e £'£trtnG✓;M1�ech.Ltlac Permit Fee: $523.00 Suppl. Insp. Fee:Q Reg. 0 OT T0.0 hrs $0.00 PhunG.:'tU£t:chJlslza Pltrmh.�Nlaclr.:%ileac Permit Fee: Consirm:fion Tru Adminim-aina>Fee: IF'e)rk N4thout Permit? Aah'lrrrBCd Planning[,ees: Tavel Documentation Fees: Strong Motion Fee: IBSEISMICO $2.64 Select an Administrative Item • Bldg Stds Commission Fee: IBCBSC $1.00 S1J9TOTALS-'j $526.64 $0.00[! :. TOTAL FEE: $526.64 Revised: 10/01/2011 - - - - N o III II I lull I I I III III III .'0 4 m � a c7 �m rC � y+r N. If1 I a 1enow81 jo; sledejed I \ y}inn s6uipIng IN u� m �m c m °z \ a y C HIM 11111111 CI s CONSTRUCTION PERMIT APPLICATION PLOT PLANb CUEC"D SY COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVI$!_ON �t 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 &PAW CUPERTINO (408)777-3228-FAX(40 -3333 -building(a)cuoertino.orD _ iPLANM DF ❑NEW CONSTRUCTION ElADDITION ALTERATION/TI ❑ REVISION/D ORIGINAL PERMI , PROIEC[ADDRMS 5 2 &7,5 PN ^rye/ OWN , P 2�/� P J J rl i'a CA I NS G 7;-7 ' ODRESS cqv, ATE.ZIP l:,v�v 13G o 6> 373 /6QL COMA PONE E-MAI. g�ak0 Aeinhard Eo Z3 � STREET ADDRESSCrrY, ATE. ZIP FAX Sr ° cn oo vL6LZ O owNER ❑ owNER-BUIDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACfORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANr CO O CrORI Li CENSE�ER CENSE TYPE BUS-UCp 2A 9N t• CO ANY NAME E-MAI. PAX C O 61V?Yl e .� 07 747 �/4 S ADDRESS `CJ17•• -IT .FG7ZIP HONE C O PO OO ARCHITECT/ENGINEER NAME LICENSENUMBER BUS.LICA COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE SCRD'TION OF WORK Desna Woo f os At IF ISTING USE PROPOSED USE CONSTIL PE aSTORIES Of 1LJ o !s USE TYPE OCC. SQ.FT. VALUATION(S) EOI.STG NEW FLOOR DEMO TOTAL AREA AREANET �j p o l% 1 . U _ BATHROOM KITCHUEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCHAREA DECKAREA TOTAL DECX/PORCH AREA GARAGEAREA DETACH ATTACH a DWELLING UNITS: IS A SECOND UNIT El YES SECONDSTORY YEs BEINCADDEDt E[NO ADDMOM. [ANO PRE-APPLICATION ❑YES RYES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: /I TOTAL VATIONn PLIN ANNGAPPLO (]NO PLANNING APPROVAL LET= EICHLERHOME? EI-KOJ U/• : By my signature below,I certify to each of the following: I am the property owner or authorized amt to act on the pipperty owner's behalf. I hate read this application and the information I have provided is correct I have read the Desorption of Work and verify it is accurate. I agree to comply with allapplicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the abovc-identified property far inspection purposes. Signature of Applicant/Agent Date: SUPPLEMENTAL INVORMATION REQUIRED PLANCRECKTYPE ROuriNG SLIP _New SFD or Multifamily dwellings: Apply for demolition permit forff'OVEI-Tt>UGDmrrEn E!BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building � � permit for new building. El EXPRESS 1��1 PLANNING 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 ❑ area Bien Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT mittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH. BldgApp_ 011.doc revised 06/21/11