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12120116CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10123 N WOLFE RD OWNER'S NAME: VALLCO SHOPPING MALL LLC CONTRACTOR? VALLCO SHOPPING MALL PERMIT NO: 12120116 LLC 10123 N WOLFE RD UNIT 1095 DATE ISSUED: 12/20/2012 OWNO'S PHONE: 4087773081 I CUPERTINO, CA 95014 1 PHONE NO: LICENSED CONTRACTOR'S DECLARATION License Class Lic. #, Contractor I hereby affirm that I 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 non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature . Date OWNER -BUILDER DECLARATION I hereby affirm that I 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) 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 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 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 n{point ur e relations per the Cupertino Municipal/Code,lection 9.18. r I II BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH RESIDENTIAL r COMMERCIAL . JOB DESCRIPTION: WEST PARKING STRUCTURE -REPLACE HOT WATER BOILER Sq. Ft Floor Area: I Valuation: $7500 APN Number: 31620107.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued bye Datee,11'2 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 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 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 as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, C apter 9.12 and the HealthNASfety , Sec ns 25505, 25533, and 255O eth r' I Z( Z Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of wrk'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. Licensed Professional 711R_ 1 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 buildingta'7.cuoertino.org Fl PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS MEP M isc PROJECT ADDRESS , 10 1 Z ?2 % I 36`�l/ 0 (S OWNERNAME Vg,11, PHONE q08, [uc- l#Z E-M- I SRE1TADDRESS/Vln3 �AM f( i GYVA' CITY, STATE, ZIP4 CONTACT NAME PHO`"miJ_ ? E-MAIL-MSTREcf ADDRESS CITY, STAZ fl FAX OWNER ❑ OWNER -BUILDER ❑ OWNERAGENr ❑ CONTRACTOR ❑CONTPACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME CJ LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME - i LICENSE NUMBER BUS. LIC COMPANY NAME ' E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD m DUPLEX ❑ 74u FAMILY BUILDING: ❑ COMMERCIAL - PROJECT IN WLLDLAND ❑ YES PROJECT IN ❑ YES URBAN INTERFACE AREA ❑ NO FLOOD TONE ❑ NO IS THE BLDG AN ❑ YES ETCF= HOME? ❑ NO DESCRIPTION OF WORK 40+ MAI�,Q r 630, le TOTAL VALUATION -D RECEIVED BY: By my signature below, I certify to each of the following: application and the information I have p ovided i orrect ordinances and state laws relating g ns cti Signature Signature of Applicant/Agent: o I am the property owner or authorized agent to act on the property owner's behalf. I have read this have read the Description of Work and verify it is accurate�I a to comply with all applicable local authorize representatives of Cupertino to enter the ab/ove- enti dprope y for inspection puposes. Date: / /2- INFORMATION REQUIRED OFFICE vsjY OVER-THE-COUNTER c Y U U ❑ EXPRESS ❑ STANDARD ❑ LARGE ❑ MAJOR MEPMircApp_ 01I.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION imADDRESS: 10123 n. wolfe rd. FEE DATE: 12/20/2012 REVIEWED BY: bobs. UNITS APN: BP#: 0// *VALUATION: 1$7,500 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building USE: $167 PENTAMATION 1CMB 1 7 PERMIT TYPE - WORK re lace comm. water boiler. SCOPE 1 APPLIANCE EQUIP TYPE FEE ID FEE QTY/FEE QTY UNITS BP FEES Boiler/Comp. <=50,hp IBBOILER(4) 1 # $167 Permit Pee: TOTALS: $167.001", 010 ----------- Mech. Plan Check 10.0 1 hrs $0.00 Plumb, Plan Check Ele£,Jllon, rMech. Permit Fee: IMPERMIT PharbA:rniit hoo: F'Iec,Permh Pee: Other Mech. Insp.�-�s $45.00 Other Phijnb frsl;. I-Iec' Insp, El lfe";h Inso, Phanix Ima hee" NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, eta). Thesefees are based on the prefindna information available and are only an estimate- Contact the Deptfor addn 7 info, FEE.ITEMS (Fee Resolution .11-053 Eff 7/11.12) FEE QTY/FEE MISC ITEMS PNE Plan Check: $0.00 Permit Pee: Suppl, Insp 17c?-,? PNE Unit Fee:: $167.00 PME Permit Fee: $45.00 Cons17puction Tax: Administrative Fee: JADMIN $42.00 Work Without Permit? 0 Yes (F) No $0.00 1,'ees: Travel Documentation Fee: I TRA VDOC $45.00 Strong Motion Fee: IBSEISMICO $1.58 Select an Administrative Item 1 Bldy Stds Commission Fee: 1BCBSC $1.00 0 T I I I I 1 $301.58 $0.0 $301.58 Revised: 10/01/2012 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - building(a)cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS (() Za wol _ APN BP# OWNERNAME V11J.,el 61jtNERADDRESS' fi �/ r 10� I V l�/ t DES IPTION OF WORK: � V We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each. statement below to signify you understand or verify this information.) 'I'"'"-1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial .risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. L6* I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. Ne�understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be Wcon icon idered an "employer" understate and federal law. 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. PC. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. AT 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any fnancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 A. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSL13 (2752) or www.cslb.ca.gov for more information about licensed contractors. (y k10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. 9 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. �"`0� 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. if you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: --NOTE: -fo-llo----------------------------------------------------------------------------------------------------------------------- Thewing Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be require to be presented when the permit is issue to ;I"Z— OwnerBuilderForm-2010.doc y the property owner's signature. Property Owner's Signature: Date: / 2z revised 04/14/10 VALLCO SHOPPING MALL NORTH SCALE: s, 1w The information contained is subject to errors and omissions. No representations, expressed or implied, are made with respect to such information. This is a proposed merchandising plan. The tenants whose names are contained herein are ones which the Leasing Agents have commenced or intend to commence discus- sions with about locating within Cupertino Square. WOLFE ROAD *macys OPEN 7� •` ' 493 SF ■ 4685 Vis] � BID ��ppp�xx cn� ilOx w f .2150 �� 2086 19 2058 y 6O 52 3 - F i� FC•, PFA OF] , • 4.6155E i w � ¢e1_sa__L_aw__1__v__ ^• �1,8539F 4 ' 493 SF 4,824 SF 4685 Vis] � ��ppp�xx cn� ilOx w f .2150 �� 2086 19 2058 y 6O 52 3 - F i� FC•, PFA OF] , • 4.6155E i w � ¢e1_sa__L_aw__1__v__ ^• �1,8539F 4 2156 •2,]44 SF • ST2155 I I rr C'-,3 G1 F BSF U- 22155,. 972 SF 28 S 5 ' l a"°°a` 21R FOOD COURT fw . .4A61 SF O9 W i� f k 1125 sF j 21651.556 sF 1.109 SF 21861,8026E I 41. - fi95SF 216> 1. d8„F , FG F1 CEGB - ' ]u-17638$ E IMF PE 3186 - ij 2 3169 �21]5 66]5 SF 1240 . 3 8 2176 1,99aSF � EI IJCPenney NORTH PARKING STRUCTURE Illll Illll Fez 9.500 SF T011 - Nil a.980 SF ALMNDERS S1EAx NOOSE SECOND LEVEL LEASING PLAN A 02 11.09.11 Iv EY i a x y JOHN HA, AIA 3 1288 Rlfa Road, #207 A S—yv le,Ca94085 Td:(408)245-0991 F.: (408) 245-0319