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11060099CITY OF CUPERTINO BUILDING P BUILDING ADDRESS: 21666 STEVENS CREEK BLVD CONTRACTOR. OWNER'S NAME: , ❑ LICENSED CONTRACTOR'S DECLARATION License Class X C� Lie. 4 �b ? 5C/ Contracto Date 0 / I hereby a m that I am 1 ensed 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 declar 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. Signature Date ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of 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) 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 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. "FRMIT NO: 11060099 DATE ISSUED: 08/02/2011 PHONE NO: BUILDING PERMIT INFO: BLDG F ELECT r PLUMB r MECH r RESIDENTIAL T_ COMMERCIAL r— JOB DESCRIPTION: MONTA VISTA MARKET - COMMERCIAL TENANT IMPROVEMENT(444SQFT) ADD PREP SINK ROOM & MOP SINK AREA FOR PRODUCT STORE.ADD 32FT PARTITIONS & 8/10/11 - REV#1 - REVISE 2 SUPPORT BEAMS, ADD ROOF CONDENSING UNIT- REVtII ISS'D 8/10/1 1 Sq. Ft Floor Area: Valuation: $30000 APN Number: 35717012.21666 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. lo Issued b Date:c 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. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(s) should 1 store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health/A Safety Code, Sections 25505, 25533, and 25534. Ow ' 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 Ad ARCHITECT'S DECLARATION Signature Date I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21666 STEVENS CREEK BLVD I rONTRArTOR- ,� , IWV� PERMIT NO: 11060099 OWNER'S NAME: I CUPERTI NO, CA 95014 I PHONE NO: I ❑ LICENSED CONTRACTOR'S DECLARATION License Class //++ Lic. M Contractor ) l.fJt^'S l ate 2 1 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. 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 no7'ce regulations per the Cupertino Municipal Code, Section 9.18. Signature Date L ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of 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) 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. 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 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. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL F COMMERCIAL f— JOB DESCRIPTION: MONTA VISTA MARKET - COMMERCIAL TENANT IMPROVEMENT(444SQFT) ADD PREP SINK ROOM & MOP SINK AREA FOR PRODUCT STORE.ADD 32FT PARTITIONS & Sq. Ft Floor Area: Valuation: $30000 APN Number: 35717012.21666 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued Gb . Date: D e l 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 1 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 fety Code, Sections 25505, 25533, and 25534. or authorized agent: 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 Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Signature Date I Licensed ���� CITY OF CUPERTINO IO'..' FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 21666 SCB DATE: 06/13/2011 REVIEWED BY: LARRY S APN: BP#: "VALUATION: 1$30,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: PENTAMATION 1M TI PERMIT TYPE: WORK ADD PREP SINK ROOM AND MOP SINK AREA FOR PRODUCT STORE. ADD 32 FEET PARTIONS SCOPE AND 22 ELEC OUTLETS, 12 ELEC FIXTURES, 8 PLUMBING SINK TRAPS. ADD 144 SQ FT WALK 0 OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEE ID BP FEES BP FEE ID M (Tenant Improvements) II-B,III-B,IV,V-B 444 $2,559.80 MTIPLNCK $626.24 IMTHNSP TOTALS: 444 $2,559.80 $626.24 MECH, HOURLY 0 Yes O No PLUMB, HOURLY 0 Yes Q No ELEC, HOURLY 0 Yes Q No Elec. Plan Check 0.0 1 hrs $0.00 ..77- Elec. Permit Fee: IEPERMT Other Elec. Insp. 0.0 hrs $42.00 NOTE: These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn 7 info. FEE ITEMS (lee Resolution 09-051 Eff. 711110) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,559.80 34 # $70.00 Electrical /BREA9tECEP Recep/Switch/Outlets Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $626.24 Suppl. Insp. Fee-.0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $42.00 Acoustical Fee: 0 Yes E) No $0.00 0 Work Without Permit? 0 Yes 0 No $0.00 Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 0 Travel Documentation Fee: ITRAVDOC $42.00 Strong Motion Fee: IBSEISMICO $6.30 Select an Administrative Item B1dy Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $3,278.34 $70.001 TOTAL FEE: 1 $3,348.34 Revised: 04/29/2011 ffim CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 21666 stvns crk blvd. DATE: 08/10/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: $300 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: PENTAMATION 1 GENCOM PERMIT TYPE: WORK revise 2 support beams add roof condensing unit. SCOPE Ll Li NOTF_t Those foo_c are hacod an lho nroliminary intarmalian availahlo and aro an1v an oclimalo_ Canlarl the non/ far addn'1 in Fa. FEE ITEMS (Fee Resolution 11-053 E . 7/1111) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? Q Yes 0 No $0.00 0 hours $130.00 Plan Check, Hourly ISTPLNCK Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feed Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes 0 No $0.00 0 Work Without Permit? 0 Yes 0 No $0.00 .Planning, Fee: $0.00 Select a Non -Residential Building or Structure Q Strong Motion Fee: IBSEISMICO $0.50 L_J # $0.00 Revision IREVSFDWL I SFDWL Bldg Stds Commission Fee: 1BCBSC $1.001 SUBTOTALS: $1.50 $130.00 TOTAL FEE: $131.50 Revised: 07/04/2011