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11090140CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: I RESULTS WAY I CONTRACTOR: XL CONSTRUCTION I PERMIT NO: 11090140 OWNER'S NAME: EMBARCADERO CAPITAL PARTNERS 1851 BUCKEYE CT DATE ISSUED: 09/20/2011 ER'S PHONE: 4089961010 I MILPITAS, CA 95035 I PHONE NO: (408) 240-6000 LICENSED CONTRACTOR'S DECLARATION j/ License Class Lic. # (0"( O Contractor 1 hereby affirm that I am licensed under the provisions o Cha er 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: 1 have and will maintain a certificate of consent to self -insure for Worker's K) 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 harmle the City of Cupertino against liabilities, judgments, costs, and expenses whic ay accrue ainst said City in consequence of the granting of this pe t. ditionally applicant understands and will comply with all non -poi s u regulation r the Cupertino Municipal Code, Section 9.18. L OWNER -BU ER DECLARATION 1 hereby a rm that 1 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 pennnit 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, C, and expenses which may accrue against said City in consequence of the L. g of this permit. Additionally, the applicant understands and will comply wiu, all non -point source regulations per the Cupertino Municipal Code, Section 9.18. BUILDING PERMIT INFO: BLDG I— ELECT r— PLUMB` MECH F RESIDENTIAL f- COMMERCIAL JOB DESCRIPTION: APPLE -BLDG 12 - DEMO/PREP- COMMERICAL, 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 b- Date: - 2 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 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 a defined bye Bay Area Air Quality Management District I will maintain co ance with The CgIfertino Municipal Code, Chapter 9.12 and the Health & y Cod;So,ions 505, 25533, and 25534. Owne C I hereby affirm tha(lt re is a construction lending agency for the performance of work's for which this perriV 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 Professiona CITY OF CUPERTINO FM_7 FEE ESTIMATOR - BUILDING DIVISION ialADDRESS: 1lresults way bldg 12 DATE: 09/20/2011 REVIEWED BY: bobs. . tr r i P r)w., I., - APN: BP#: _....... -- "VALUATION: 1$50,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY Commercial Building USE: i .. PENTAMATION 1TIPREP PERMIT TYPE: WORK demo/ re commercial offices ace interior only. SCOPE PME Plan Check: NOTE: This estimate does not include fees due to other Depts (ba Public Works, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/11) FEE QTY/FEE Etre. i'wli Ci,i cf . tr r i P r)w., I., - __. Li 0 # $380.00 Tenant Improvement Prep ITIPREP i .. Suppl. PC Fee: (F) Reg. 0=0T] NOTE: This estimate does not include fees due to other Depts (ba Public Works, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 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: (F) Reg. 0=0T] 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 s. 'tF�a.rlr•rt: •ri c1t1 7� r.t £clnr:ni: tr tti+ : l E Q 0 Work Without Permit? Q Yes No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure Q 0 Strong. Motion Fee. IBSEISMICO $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