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11060006CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20041 BOLLINGER RD CONTRACTOR: BANG'S ELECTRIC PERMIT NO: 11060006 OWNER'S NAME: PACIFIC RIM PARK, LLC 18940 NEWSOM AVE DATE ISSUED: 07/07/2011 OWNER'S PHONE: 4082554163 CUPERTINO, CA 95014 PHONE NO: (408)378-9971 ❑ LICENSED CONTRACTOR'S DECLARATION PERMIT PLUMB License Class tni�� Lic. # �� " �C � � BUILDING INFO: BLDG ELECT �""` �'""` �""` MECH RESIDENTIAL COMMERCIAL rr � Contractor �jM1 �1 L tlf-Cf .LG 4C0 Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: TI-COMMERCIAL(2955SQFT),NON-STRUCTURAL (commencing with Section 7000) of Division 3 of the Business & Professions INCLUDES NEW PARTITIONS, DOORS, ACCESSIBLE RESTROOMS, Code and that my license is in full force and effect. MODIFY EXISTING MECH,ELECT, PLUMBING& MINOR 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 t s Sq. Ft Floor Area: Valuation: $79500 permit is issued. APPLICANT CERTIFICATION APN Number: 36934052.20041 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non -point source regulations per the Cupertino Municipal Code, Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. l �l Signature� Date / Issued b Date: ❑ OWNER -BUILDER DECLARATION I hereby affirm that 1 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 berg 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: 1 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 I have and will maintain Worker's Compensation Insurance, as provided for by California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain Section 3700 of the Labor Code, for the performance of the work for which this compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & 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 I 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. th Owger o ad agent: l �v L/ Date:4LO/ 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, costs, and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section ARCHITECT'S DECLARATION 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO FM__7 FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 20041 bollinger rd. DATE: 06/01/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$79,500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: PENTAMATION 1 E TI PERMIT TYPE: WORK t.i.comm. business space non structural includes new partitions, doors accessible restrooms modify SCOPE existing mech. elect. plumbing, minor exterior accessible compliance. OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.L PC FEES PC FEE ID BP FEES BP FEE ID E (Tenant Improvements) II-B,III-B,IV,V-B 2,955 $3,684.40 IETIPLNCK $3,931.20 IETIINSP TOTALS: 2,955 $3,684.40 $3,931.20 MECH, HOURLY 0 Yes (F) No PLUMB, HOURLY 0 Yes Q No ELEC, HOURLY 0 Yes Q No Li i��-,,1� 1rtt1�. !e{r. ,; ':•t•: tl�,r.lrx;t� f''irc: NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 09-051 E . 711110) FEE QTYIFEE MISC ITEMS Plan Check Fee: $3,684.40 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $3,931.20 SuppL Insp. Feed Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 i. onstruct ion Tax Acoustical Fee: 0. Yes (E) No $0.00 0 E) Work Without Permit? 0 Yes (3) No $0.00 Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 O 7"r<►� 1 I)o!;rrrsr ,?r�stin�� F`� �: Strong Motion Fee: 1BSEISMICO $16.70 Select an Administrative Item Bldg; Stds Commission Fee: IBCBSC $4.00 SUBTOTALS: $7,636.30 $0.00 TOTAL FEE: 1 $7,636.30 Revised: 04/29/2011