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11080073 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10023 S DE ANZA BLVD CONTRACTOR:T PERMIT NO: 11080073 OWNER'S NAME: MARDESICH CO.CROSSROADS,LLC. Vr Q Its �:� ``c, DATE ISSUED:08/09/2011 C "ER'S PHONE: 8016021426 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG T— ELECT PLUMB r License ClassLic # l U . y 1�, MECH RESIDENTIAL� COMMERCIAL Contractor r- Ir' Q--L,­,— Date `5�' I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CHEVRON-INSTALL ELECTRICAL SWITCH/RECEPTACLE (commencing with Section 7000)of Division 3 of the Business&Professions FOR Code and that my license is in full force and effect. BLOCKBUSTER VENDING MACHINE 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. Sq.Ft Floor Area: Valuation:$400 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:35908019.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. AoAkimrah,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point sourc regulati per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date iff ' Al, Issued by: Date: OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I 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 Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air 1 certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. 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. Ower uth ed agent: Date: LS APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, r and expenses which may accrue against said City in consequence of the Lender's Address L ig of this permit.Additionally,the applicant understands and will comply wim all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 13 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35908019. 00 DATE ISSUED. . . . . . . : 08/09/2011 RECEIPT #. . . . . . . . . BS000014367 REFERENCE ID # . . . : 11080073 SITE ADDRESS . . . . . : 10023 S DE ANZA BLVD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER MARDESICH CO. CROSSROADS, LLC. ADDRESS 10023 S DE ANZA BLVD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : OR-AN BLAUSTEIN 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1. 00 41. 00 0 . 00 41 .00 0. 00 1BCBSC VALUATION 400 . 00 1. 00 0 . 00 1. 00 0. 00 1BREMRECEP NO. OUTLETS 1 .00 44 . 00 0. 00 44 . 00 0 . 00 1BSEISMICO VALUATION 400 . 00 0. 50 0. 00 0 .50 0 . 00 1EPERMITFE FLAT RATE 1. 00 44 . 00 0 . 00 44 .00 0. 00 1TRAVDOC FLAT RATE 1 .00 44 . 00 0. 00 44 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 174 . 50 0 . 00 174 .50 0 . 00 GENERAL PERMIT APPLICATION _ MEP - COMMUNITY DEVELOPMENT DEPARTMENT. BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERT[NO (408)777-3228 • FAX (408)777-3333• building(aDguDertinc.crq misc ❑PLUMBING ❑bIEC-1t CAL ELECTRICAL ❑INUSCELLAINECUS PROJECT ADDRESS 1002,-S S . �� ��+� / APN T OWNER NAME / ' ,^ PHONE c6'0 t U Z I l E-MAIL STREET ADDRESS CITY, STATE,ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACl'ORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR N LICENSE NUMBER LICENSE TYP BUS.LIC 4 COMPANY NAME E-MAIL FAX ,(CQ S STREET ADDRESSI ' R �O CITY,STATE,�P C C1 ARCHITECT/ENGINF.ER NAME l �a! LICENSE NUMBER (' 3US.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE SE OF ❑SFD or DUPLEX ❑ MULTI-FANIIY PROIECT INWIIALAND ❑ YES PROTECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NNo J f� MCI=HOME? ❑'NO DESCRIPTION OF WORK S C -c-OL TOTAL VALUATION: y(1 Q RECEIVED BY: By my signature below,I certify to each of g: I am the property owner or author.zed agent to act on the property owner's behalf. I have read this application and the information I ve p v'ded is carr ct.,J have read the Description of Work and verfy it is accurate. I agree to comely xith all applicable local ordinances and state laws rela' g b ]ding constru "on. I authorize representatives of Cupertino to enter the ab dengnedlpro perry for inspection purposes. Signature of ApplicandAgent Date: SUPPLEMENTAL INFORMATION REQ=-D OFFIc i USE ONLY OVER-THE-COUNTER a ❑ EXPRESS Y U w ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPLIsscAPP_3011.doc revised 06/31/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10023 s. de anza blvd DATE: 08/09/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $400 R'PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY Commercial BuildingPENTAMATION 10EAP10 USE: PERMIT TYPE: WORK install electrical switch/receptacle for vending machine. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Recep/Switch/Outlets 1 BREMRECEP 1 # $44 TOTALS: $44.00 Elec.PlanCheck 0.0 hrs $0.00 Elec.Permit Fee: ]EPERMIT Other Elec.Insp. 0.0 hrs $44.00 NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (hie Resolution 11-05;1'ff.' " -l1) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 A Strong Motion Fee: IBSEISMICO $0.50 0.5 hrs Admin./Clerical Fee Bldg Stds Commission Fee: 1BCBSC $1.00 $41.00 ]ADMIN SUBTOTALS: $133.50 $41.00 TOTAL FEE: $174.50 Revised: 07/04/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: (n O Z PERMIT# OWNER'S NAME: PHONE # /g"• Z C�3/ 3 GENERAL CONTRACTOR: S ` BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SU C RS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 9 I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum /Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO BUILDING PERMI 10140 BUILDING ADDRESS: 10500 N DE ANZA BLVD FLR 1 CONSTRUCTION INC N NER'S NAME: APPLE 690 GIBRALTAR DR DATE ISSUED:03/09/2011 OWNER'S PHONE: 4088629799 MILPITAS,CA 95035 PHONE NO:(408)942-8200 16 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT PLUMB r License Class;__ Lic.# MECH RESIDENTIAL COMMERCIAL Contractor })) ✓_V ��ti� �'�Z�5"1 Date JOB DESCRIPTION: T1,3016 SF,FLOOR I,INCLUDES FOUR NEW EQLIIPMEN"f 1 hereby affirm that I am licensed under the provisions of Chapter 9 CHAMBERS,OFFICES,AND MEE'TING ROOM. NO EXTERIOR (commencing with Section 7000)of Division 3 of the Business&Professions WORK OR ROOF MOUNTED EQUIPMENT INCUDES Code and that my license is in full force and effect. 6/1/11-DEP#1 -DEFERRED SUBMITTAL FOR INSTALLATION 01' I hereby affirm under penalty of perjury one of the following two declarations: TESTING CHAMBERS AT 1 ST FLOOR LAB-ISSD 8/4/2011 1 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 Valuation:$450000 performance of the work for which this permit is issued. Sq.Ft Floor Area: 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 APN Number:31622017TLR I Occupancy Type: permit is issued. / APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY /FROM LAST CALLED INSPE�TIQN. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Issued by: C G Date: granting of this permit. Additionally,the pplicant understands and will comply with all non-point source regulations er he Cupertino Municipal Code,Section 9.18. � A �c, RE-ROOFS: 1'�-nature / Date C/ All roofs shall be inspected prior to any roofing material being installed If a root is installed without first obtaining an inspection,1 agree to remove all new materials for inspection. Cl OWNER-BUILDER CLARA" N Signature of Applicant:_ Date: I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: 1,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) HAZARDOUS MATERIALS DISCLOSURE 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Muni ipal Code,Chapter 9.12 and the Health&Safety Code,Sects 25505,25533' n 25534. 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 Owner or authorized agent:' �'" Date- Owner permit is issued. I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCT ION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,1 become subject to the Worker's Compensation provisions of the Labor Code,I must 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.) forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name APPLICANT CERTIFICATION Lender's Address - I certify that 1 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 -,-)oil the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION emnify and keep harmless the City of Cupertino against liabilities,judgments, ,sts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional_ 9.18. Signature Date