11090139CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: I RESULTS WAY
OWNER'S NAME: EMBARCADERO CAPITAL PARTNERS
O WS PHONE: 4089961010
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #`�'
Contractor CW,1 f Ail �� Date Q Ci
I hereby affirm that 1 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.
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 15
Section 3700 of the Labor Code, for the performance of Ute work for which this
pen -nit 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 whic ay accrue against said City in consequence of the
granting of this per it. ditionall ,the ap cant understands and will comply
with all non-poin ou regulati per t Cupertino Municipal Code, Section
9.18.
Signature Date
CI I OWNER -BUILDER DECLARATION
1 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).
1 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, 1 must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONTRACTOR: XL CONSTRUCTION PERMIT NO: 11090139
851 BUCKEYE CT DATE ISSUED: 09/20/2011
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. 1 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
ind-mnify and keep harmless the City of Cupertino against liabilities, judgments,
tnd expenses which may accrue against said City in consequence of the
jig of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
MILPITAS, CA 95035 I PHONE NO: (408)240-6000
BUILDING PERMIT INFO: BLDG r— ELECT f— PLUMB
MECH r_ RESIDENTIAL { COMMERCIAL
JOB DESCRIPTION: APPLE: BLDG I I - DEMO/PREP- COMMF,RICAL OFFICE.
SPACE
INTERIOR ONLY
Sq. Ft Floor Area: I Valuation: $50000
APN Number: 35720041.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued b3✓'�^ f-' . .— _-___.... Date: 111-2
RE -ROOFS:
All roofs shall be inspected prior to any rooting material berg 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
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 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 t Bay Area Air Quality Management District 1 will
maintain compliance with t Cu ertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sec ns ;505, 25533, and 25534.
Date:* -
ate: r
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.
Signature Date I Licensed Professional
CITY OF CUPERTINO
FM_7 FEE ESTIMATOR - BUILDING DIVISION
NOTE. This estimate does not Include fees due to other Depts (1. e- Public Works, Sanitary Sewer District, School District, etc.).
These tees are based on the nreliminary information available and are onlv an estimate: Contact the Dent for addn'l info.
FEE ITEMS (Fee Reso/ulion 11-053 E[/ 7/1/11)
ADDRESS: 11results way bldg 11
DATE: 09/20/2011
REVIEWED BY: bobs.
APN:
BP#:
"VALUATION: 1$50,000
"PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
USE:
Suppl. PC Fee: E) Reg. 0 OT
PENTAMATION 1TIPREP
PERMIT TYPE:
WORK
demo/prep commercial offices ace interior only.
SCOPE
NOTE. This estimate does not Include fees due to other Depts (1. e- Public Works, Sanitary Sewer District, School District, etc.).
These tees are based on the nreliminary information available and are onlv an estimate: Contact the Dent for addn'l info.
FEE ITEMS (Fee Reso/ulion 11-053 E[/ 7/1/11)
FEE
N'
. .
Fj:
!'ifrtr�r,tl.•�.•h.Irtv�;.
r?'ia•,r1'i:u�:;;ir;,Lj
._Ll
Suppl. PC Fee: E) Reg. 0 OT
0.0
NOTE. This estimate does not Include fees due to other Depts (1. e- Public Works, Sanitary Sewer District, School District, etc.).
These tees are based on the nreliminary information available and are onlv an estimate: Contact the Dent for addn'l info.
FEE ITEMS (Fee Reso/ulion 11-053 E[/ 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
0 #
$380.00
Tenant Improvement Prep
ITIPREP
Suppl. PC Fee: E) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -0 Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
C on,Ntrtwtiun Tax
.441,nn:ni�ly rvve l=ee,
0
E)
Work Without Permit? Q Yes (D No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
E)
0
Ci-Uve l Documentation Fein :
Strong Motion Fee: 1BSEISMICO
$10.50
Select an Administrative Item
Bldg; Stds Commission Fee; IBCBSC
$2.00
SUBTOTALS:
$12.50
$380.00
TOTAL FEE:
$392.50
Revised: 09/02/2011