11020051CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10123 N WOLFE RD MAIN CONTRACTOR: VALLCO �'T= ..�=L-StIO MG f PERMIT NO: 11020051
sio i
OWNER'S NAME: VALLCO INT'L SHOPPING CENTER 10123 N WOLFE RD #ra�� ' DATE ISSUED: 03/23/2011
OWNER'S PHONE: 4087773081 CUPERTINO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOIt! SDECLARATION F
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. #
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter`9 JOB DESCRIPTION: LOWER LEVEL --COMM T.I OF 10,000 SQ FT NEW
(commencing with Section 7000) of Division 3 ,of the. Business &Professions RESTROOMS, STORE FRONTS
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 twself-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permitis issued.
I have and will maintain Worker's Compensation Insurance, ;as provided for by
Section 3700 of the Labor Code, for the perforrrianee 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 Cupeft'ino'against liabilities; judgments,
costs, and expenses which may accrue against said' -City in consequence of the
l.
this permit: Additionally, the applicant understands and will comply
with all non -point source regulations per ithe Cupertino Municipal Code, Section
Sq. Ft Floor Area: I Valuation: $188000
APN Number: 31620107.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
9.18. Issued Date:
Signature Date
❑ 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 withtlicensed 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 toy 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 i's:ssued.
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 thispermit shall be deemed revoked,
APPLICANT CERTIFICATION
I certify that I have read this application and state that the abc
correct. I agree to comply with all city and county, ordinances
to building construction, and hereby authorize representative;
upon the above mentioned property for inspection purposes:_
indemnify and keep harmless the City ofCuperdito against It
costs, and expenses which may accrue against'said City inw
granting of this permit. Additionally, the applicant understain
with all non -point source regulations per=the Cupertino Muni
9.18. .
Sienature&u Date
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being 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(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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Co e, Sections 25505, 25533, and 25534.
Own t ent• -3 W//
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of wrles
hrmation is for which this permit is issued (Sec. 3097, Civ C.)
state laws relating Lender's Name
us city to enter
agree to save Lender's Address
ies, judgments,
will-
of the
il comply
ARCHITECT'S DECLARATION
will
Code, ection I I understand my plans shall be used as public records.
Licensed
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10123 N WOLFE RD MAIN
or R'S NAME: VALLCO INT'L SHOPPING CENTER
CONTRACTOR: VALLCO INT'L SHOPPINGI PERMIT NO: 11020051
CENTER
10123 N WOLFE RD #2030
DATE ISSUED: 03/23/2011
OWNER'S PHONE: 4087773081 I CUPERTINO, CA 95014 I PHONE NO: I
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic.#,
Contractor 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 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 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.
S' re
Date
❑ 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)
1, 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 'ding construction, and hereby authorize representatives of this city to enter
U, ie 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. . I %i
Date ✓ Z
BUILDING PERMIT INFO: BLDG I' ELECT F PLUMB r`
MECH I— RESIDENTIAL r COMMERCIAL r—
JOB DESCRIPTION: LOWER LEVEL --COMM T.I OF 10,000 SQ FT NEW
RESTROOMS, STORE FRONTS
Sq. Ft Floor Area: I Valuation: $188000
APN Number: 31620107.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued
Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being 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(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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Own t ent: ,j 1,_73111
Date:-
CONSTRUCTION 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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF
CITY OF CUPERTINO
TENANT IMPROVEMENT
CUPERTINO PERMIT APPLICATION FORM
" / I I 09�(n5-1
APN #l.P d-b�� .
Date: Z1 / L/
� I
Building Address: 1017i� WOO
Mailing Address (if different from building address):
Tenant ❑ (If tenant please provide a letter from the building owner approving the tenant improvement.)
Building Owner EJ -
Are Hazardous Materials being used as part of this project? Yes ❑ No
/
Te an y�ildings er's Nam
/
• Q If
/
Phone #O
S 777 3 09- I
Contractor:
Phone #:
$ ccG
Fax #: 72-5- 0-3'7 G
Cupertino Business License: State Contractor License #:
Corilact:
�Jo m(k, 120U
Phone #: zc q 3q0
e C-41
Fax /e-mail:
Landscape Ordinance Compliance:
Landscape area in sq. ft. (includes all irrigated areas):�,A,
If 2,500 sq. ft. or less, compliance with the Landscape Water -Efficiency Checklist is required.
If more than 2,500 sq. ft., a complete Landscape Project Submittal is required.
Compliance Method: ❑ Plant Type ❑ Water Budget
Job Description (be specific):
le� . .2 a� (� ��u ��t �/ Ce rem .. CuL47
to, 049 0
Tenant Improvement Includes Re -Roof Yes ❑ No Z/if yes, number of squares ,
Tenant Improvement Includes Structural Yes ❑ No ['
Type of Construction (Usage Class):
Occupancy Type: 1
1-A, 1-B ❑ IUIII/V-A ❑ IUIII B, IV -HT, V -B
Valuation: 1 fS`U, Q 0 o
Project Size: Counter 0 Express ❑ Standard Large ❑ Major ❑
Green Building: Please complete Leed for commercial interiors checklist & attach it to the application
or if applicable, include in plans & sheet index
LEED Points Achieved }
*** For Office Use Only*** Revised 12-06-10
CITY OF CUPERTINO
WE FEE ESTIMATOR — BUILDING DIVISION
OCCUPANCY TYPE:
10123 n.wolfe rd.
DATE: 02/14/2011
REVIEWED BY: bobs.
JimADDRESS:
APN:
BP#:
*VALUATION: 1$188,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
USE: Commercial Building
IATIPLNCK
PENTAMATION
PERMIT TYPE: 1A TI
WORK
commom mall area includes new store front restroom
[!LcLOMmercial
SCOPE
$0.00
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
A (Tenant Improvements)
II-13,111-13,IV,V-13
10,000
$2,557.00
IATIPLNCK
$4,525.00
IATIINSP
PME Plan Check:
$0.00
Permit Fee:
$4,525.00
Suppl. Insp. Feer Reg. ® OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Conswuction Tax
TOTALS:
10,000
$2,557 00
K
$4,525 00
Nl1TF• Thoco fOOQ "no hncad nn tho nrolimin"m infnrmatian availahle and are ank an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 09-051 E . 7/1/10)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,557.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: E) Reg. 0 0T70,0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$4,525.00
Suppl. Insp. Feer Reg. ® OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Conswuction Tax
Acoustical Fee: ® Yes 0 No
$0.00
Work Without Permit? ® Yes G No
$0.00
Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
0
0
Travel Documentation Fees:
Strong Motion Fee: IBSEISMICO
$39.48
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$8.00
$7,129.48
$0.00�� 3e -
$7,129.48
Revised: 01/15/2011
CUPERTINO
OWNER -BUILDER DISCLOSURE FORMA
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 85014-3255
(408) 777-3228 • FAX (408) 7T7-3333 • buildinora)cuoeriino.ora
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property,
improvements specified at:
SITE ADDRESS.
tot F+iC
APN
BP/v
OWNER tArylE�
f�I
OWNER ADDRESS W014 f p
DESCRIPTION OF WORK:
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS. Please read and initial each statement below to signify you understand or verify this information.)
. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Buil r" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage -,fpr those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
• 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
N�' W9. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
40'_4.1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
WL25. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
red an "employer" under state and federal law.
ooW6. J
1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
A—K I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work -
is performed under contract with a licensed general building Contractor.
I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials..
Olvi2erBuilderForni 2010.doc revised 04/14/10
44. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
A02 -10.
A
Y 02 0. i am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
(M11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial foss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification acceptabLto the ity maybe required to be presented when the permit is issued
to verify the prope owner's sii t
Property Owner's Signature: Date: 3 Z3 /
------------------------------------------------------------------------------------------------------- --------------------------------------
(NOTE. The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Lopation or Address:
Name of Authorized Agent:
Address of Authorized Agent:.
Tel No
declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the properly owner's
signature.
Property Owner's Signature:
Date:
CiwerBuilderFonn 2010.doc revised 04114110
4P