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11040183 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: STEVENS CREEK BLVD 2 0-1 tf CONTRACTOR: PERMIT NO: 11040183 OWNER'S NAME: TARGET STORE e DATE ISSUED:04/26/2011 OWNER'S PHONE: 4087252651 , PHONE NO: LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# Zli `1;kO MECH RESIDENTIAL COMMERCIAL Contractor �l�'��7L- ��c� :c Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD 12 RECEPTICLES TO RELOCATE RECEPTICLES AT (commencing with Section 7000)of Division 3 of the Business&Professions DATA DEPT 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 whirthis permit is issued. ; Sq.Ft Floor Area: Valuation:$9000 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:32632055.00 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. 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. Signature Z ZZ Date yrZ 6' Issued �� \ Date: r 04— v 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: 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 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. Owner or authori a t �� Date: 121-Z6—// l- z6.// APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 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, C and expenses which may accrue against said City in consequence of the Lender's Address ag of this permit.Additionally,the applicant understands and will comply wnu 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 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32632055.00 DATE ISSUED. . . . . . . : 04/26/2011 RECEIPT #. . . . . . . . . : BS000013298 REFERENCE ID # . . . : 11040183 SITE ADDRESS . . . . . : STEVENS CREEK BLVD SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : TARGET STORE ADDRESS . . . . . . . . . . : 20745 STEVENS CREEK BLVD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : NAPA ELECTRIC 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 ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 9, 000.00 1. 00 0. 00 1.00 0. 00 1BREMRECEP NO. OUTLETS 1.00 42 . 00 0. 00 42 .00 0. 00 1BSEISMICR VALUATION 9, 000 .00 0. 90 0. 00 0 .90 0. 00 1EPERMITFE FLAT RATE 1.00 42. 00 0. 00 42 .00 0. 00 1TRAVDOC FLAT RATE 1 .00 42. 00 0. 00 42 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 127. 90 0.00 127. 90 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 127. 90 #099905 --------------- TOTAL RECEIPT 127. 90 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL 512 FINAL HANDI-CAP CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20745 scb DATE: 04/26/2011 REVIEWED BY: APN: BP#: "VALUATION: 1$9,000 RPERMITTYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Du lex PENTAMATION 1 REAP10 USE: p PERMIT TYPE: wORK add 12 rece ticles to relocate rece ticles at data dept. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Recep/Switch/Outlets 1 BREMRECEP 12 # $42 TOTALS: $42.00 Elec.Plan Check 1 0.0 1 hrs $0.00 „ , ,„ rr,,r Elec.Permit Fee: IEPERMIT F-1 Other Elec.Insp. 0.0 hrs $42.00 L--] NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS(Fee Resolution 09-051 E : 7,'1,'10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 -T PME Unit Fee: $42.00 PME Permit Fee: $42.00 Work Without Permit? O Yes No $0.00 Travel Documentation Fee: ITRA VDOC $42.00 Stron�)-rMotion Fee: IBSEISMICR $0.90 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $127.90 $0.00 TOTAL FEE: $127.90 Revised: 04/01/2011 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•buildingCcl?cupertino.org MISC CUPERTINO ❑PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS �/ i APN N OU4fERNAME PHONE. � //� � E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX CONTACT NAME // PHOE-MAIL STREET ADDRESS _ CITY,SPATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC N ,�(/. >;. �i`�� f•' ._;y ;'y c' icy ? � %`7 COMPANY NAME E-MAIL ` 1 FAX /!�r. �" ¢./r< /'it �.lr�C: r� %'• /?� x;,`lrc Ic,� �- �^- �c;�� :'s� LI�F-,�, STREET ADDRESS CITY,STA'L'E,ZIP PHONE .. ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF ❑ SFD or Duplex 0 Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK TOTAL VALUATION: r� RECEIVEIkBY < By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I thorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: /1' / Date: SUPPLEMENTAL INFORMATION REQUIRED _ -�. r• �sE� mow' ---- _rAR MEPMiscApp_201 Ldoc revised 03/16/11