12050018CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10889 S BLANEY AVE
CONTRACTOR: JON R CRASS
PERNI IT NO: 12050018
CONSTRUCTION INC
OWN'ER'S NAME: PACIPIC RIM PARK LLC
164GILMANAVF,STEA
DA'Z'E ISSUED: 05102/2012
OWNER'S PHONE: 4082554163
CAMPBELL. CA 95008
PUONE NO: (405)370.1485
❑ LICENSED CONT'RACTOR'S DECLARATION
r r r
License Classi Lic fl 101LI-547
BUILDING PERMIT INFO: BLDG ELECT PLUMB
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MECH RESIDENTIAL COMMERCIAL
qq
Contractor Dale S P
1 hereby affirm that 1 am licensed under the provision of C tapler 9
JOB DESCRIPTION: DAMAGE REPAIRS CAR DAMAGE, APPROX 5
(commencing
(commencing with Section 7000) of Division 3 of the Business & Professions
SQFT
PLUS CLACING
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 I'or which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: $10536
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 36934052.10889 Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
coffee(. 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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnifynd harness the City ofCupertinosato against liabilities.judgments.
which
costs, and expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature �iuLf/ Date a- a
``
Issued by: �EAN fi TG� Date: J'r_7'�,�—
❑ OWNER-1111ILDER DECLARATION
RF. -ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection. I agree to remove all new materials for
1, as owner of (he property. or nn' employees with wages as their sole compensation,
inspection,
will do the work, and the structure is not intended or offered for sale (Sec7044.
Business & Professions Code)
Signature of Applicml: Dale:
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
AL1, ROOF COVERINGS TO BE CLASS "A" OR BETTER
1 hereby affirm under penalty of perjury one of the fallowing three
declarations:
I have and will maintain a Cenificalc of Consent to self -insure for Workers
DA"LARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the labor Code, for the
1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of (he work for which this permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Iiealth &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emil hazardous air
permit is issued
contaminants as defined by the Bay Area Air Quality Management District I will
I certify (hal in (he performance of the work for which this permit is issued, 1 shall
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Workers
Health & Safety Code, Sections 25505, 25533, and 25534.
Compensation laws of California. 11. alter making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I mustwne�tborize
,1
�--
fonhwi(h comply with such provisions or this permit shall be deemed revoked.
'�='�� Date:
L�
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that [here is a construction lending agency for the performance of wark's
correct. I agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (See. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses m%hich nmy accrue against said City in consequence of the
granting of This permit Additionally, the applicant understands and will comply
ARCIIITF.C`I S DECLARATION
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
1 understand my plans shall be used as public records -
Signature Date
Licensed Professional
3 ITEMS OF 3
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 36934052.10889
DATE ISSUED.......: 05/02/2012
RECEIPT #.........: BS000016678
REFERENCE ID # ...: 12050018
SITE ADDRESS .....: 10889 S BLANEY AVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: PACIFIC RIM PARK LLC
ADDRESS .....-.....: 5057 FOREST GLEN DR
CITY/STATE/ZIP ...: SAN JOSE, CA 95129
OPERATOR: patg
COPY # : 1
RECEIVED FROM .. : JON R CRASE CONST
CONTRACTOR .......: JON R CRASE LIC # 22250
COMPANY ..........: JON R CRASE CONSTRUCTION INC
ADDRESS ..........: 164 GILMAN AVE STE A
CITY/STATE/ZIP ...: CAMPBELL, CA 95008
TELEPHONE ........: (408)370-1485
FEE ID UNIT
QUANTITY
AMOUNT PD
-TO -DT
THIS REC
NEW BAL
---------- -------------
1BCBSC VALUATION
----------
10,536.00
---------- ----------
1.00
0.00
----------
1.00
----------
0.00
1BSEISMICO VALUATION
10,536.00
2.21
0.00
2.21
0.00
1STINSP UNITS
3.00
390.00
0.00
390.00
0.00
TOTAL PERMIT
----------
393.21
---
0.00
----------
393.21
----------
0.00
METHOD OF PAYMENT
AMOUNT
REFERENCE
NUMBER
----------------- ---------------
CHECK
393.21
-------------
#62174
---------------
TOTAL RECEIPT
393.21
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255
(408) 777-3228 • FAX (408) 777-3333 • buildingCc)G cuoerlino.orD
❑PLUMBING . ❑MFCRANICA.L ❑ELECTRICAL I IIvIISCEEr NFOUS
MEP
MIST
PRO= AD g� s. a►4e: - �'°
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OWNERN A.Ga Ci 2\N11 eL4.+ L
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PHONE E-MAIL
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CITY, STATE. ZB• �os� �s►aq
FAX
CDNTAcr NAME
STREXTADDRESS ,-
QTY, TE, ZlP
FAX
❑ OWNER ❑ OWNERBUILOM 0 NERAGINf- ❑ CONTRACBBR ❑ CONTRACTOR AGENT ❑ ARODrF1.T ❑ E axe Et ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAM�.1�- ' I f
[ICFNNUMBER &I/C97
ts97
LICENSE TYPE YI
BUS. LIC pN r7�a
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COMPANY NAME •�"W%%L R -.C— •
ESE
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STREETADDRFS/wi 4, �
aTY.sr� �.. bw�U CA IS -DOT
"MOV) i7v-PIC'S
ARCICTECTIEJGINEER. NAME
LICENSE NUAMER
BUS. DC F
COMPANY NAME
E-MAIL
FAX
STREETADDRESS
CITY, STATE Z37
PHONE
USE OF ❑SFBmOrrPIPX ❑ WULTFFAMMY
BUDDING: I�COMM cIAL
PROXECTINWIIDIAND❑YES
URBAN INTERFACE AREA ❑NO
PR rTIN ❑ YES
Fi000 ZONE ONO
ISTHEBLDOAN 13 YES
EICHLER NOME? ❑NO
DESCRIPTION OF WOAX
f eJ� ES
TOTAL VALUATION(� �36,
RECEIVED BY
By my signature below, I certify to each of the following: I am the property owna or anthorized agent to as oo the property awods behalf I have read chis
application and the information I have provided is correct) have read the Dewiptian of Work end verify it is accenam. I agree to comply with all applicable local
ordinances and state laws relating to g I aothoriu reptesantauves of Cupertino to en[a the above.idendfled property for inspection pul poses.
Signature ofAppliesvVAgent Dam:
SUPPLEV04TAL INFORMATION REQUIRED
FFICE USE ONLY
m
OVER -TBE -COUNTER
d
Y
❑ EXPRESS
u
u
'u
❑ SrANDARD
3
❑ LARGE
6
❑ MAJOR
MSPMucApp_2011.doc revised 0621111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ia'ADDRESS:
10889 s. blaney ave DATE: 05/02/2012
APN: BP#:
REVIEWED BY: larry s
'VALUATION: $0
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
USE: CommercialBuilding
BP FEE ID
PENTAMATION
PERMIT TYPE: 1BT1
WORK
ama a repairs -minimal car damage, approx 5 sq. ft plus glacing
SCOPE
Other /;Ice. Insp.
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
B (Tenant Improvements)
II-B,111-B,IV,V-B
0
$0.00
Other /;Ice. Insp.
$0.00
PhmIb. Insp. Fee:
tiler. Insp. F, o:
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? ()Yes 0 No
$0.00
Suppl. Insp. Fee -.0 Reg. O OT 0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
TOTALS:
0
1 $0.00
Constt'11cli Un l(I.A.,
$0.00
MECH, HOURLY O Yes (E) No
PLUMB, HOURLY O Yes 0 No
ELEC, HOURLY O Yes O No
.th �:lr. l'Irrn C'h,�rA
Phunb. Plem Check
flee. Plan Cheek
Nech. Pvrnril Fee:
Plumb. Pevmrii Fee:
lilec. Pu'mir Fee:
Other ,llech. Ing.
Otlrcr Plumb Insp.
Other /;Ice. Insp.
Ma, h. bt"p. lire:
PhmIb. Insp. Fee:
tiler. Insp. F, o:
NOTE: This estimate does not includejees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These fees are based on the Prelimina information available and are only an estimate Contact the De 1 or addn7 info.
FEE ITEMS (Fcc Resolulion 11-053 Eff 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: Q Reg. O OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? ()Yes 0 No
$0.00
Suppl. Insp. Fee -.0 Reg. O OT 0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Constt'11cli Un l(I.A.,
Adinini.curalive Fee:
O
G
Work Without Permit? O Yes (E) No
$0.00
Advanced Plannine Fee:
$0.00
3 hours Inspections
$390.00 ISTiNSP Inspection, Hourly
O
Travel Docootentation Fees:
Stronc Motion Fee:
$0.00
Select an Administrative Item
131(1a Stds Commission Fee:
$0.00
SUBTOTALS:
$0.00
$390.00
TOTAL FEE:
$390.00
Revised: 04/01/2012
OPP ENT DEP ENT
ro .
SIOt' CUPERTIN
dhls of ansr�n eclfdaiions M. be kept at the
jib(S , c,d� ctlon. It is unlaa�ff I to make any
64 dr�,@yt tionY on jiamr c devviate
r ` 4 TVie� pro al,from th Efuildin Official.
�R h y Ian g spec) ,tj/ions SHALL NOT
f�. . � to bf� appr
,. I of the violation
any CsGy Ord . ce or State Law.
BY
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