11010121CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10450 BUBB RD
OWNER'S NAME: MISSION WEST
OWNER'S PHONE: 4089741126
❑ LICENSED CONTRACTOR'S DECLARATION
LicenseClassA Lic.# 37-171 L
Contractor C MEA,, Date 1/
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.
1 hereby affirm under penalty of perjury one of the following two declarations:
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
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:
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).
1 hereby affirm under penalty of perjury one of the following three
declarations:
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
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
1 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
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.
CONTRACTOR: DICKINSON CAMERON PERMIT NO: 11010121
CONSTRUCTION CO
6184INNOVATION WAY DATE ISSUED: 03/28/2011
CARLSBAD, CA 92009 PHONE NO: (760) 438-9114
BUILDING PERMIT INFO: BLDG I- ELECT F_ PLUMB I-
MECH r- RESIDENTIAL r- COMMERCIAL r
JOB DESCRIPTION: COMM'L TI (6,000SQFT)- MOCK UP OF AN APPLE RETAIL
STORE WITH AN EXISTING LEASE SPACE; NO RE -ROOF &
HASSTRUCTURAL
Sq. Ft Floor Area: I Valuation: $50000
APN Number: 35720037.10450 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued bDate:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Date ° 2.- (
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records.
Signature Date I Licensed Professional
h0l 0[2-1
CUPERTINO
CITY OF CUPERTINO
TENANT IMPROVEMENT
PERMIT APPLICATION FORM
APN # /� 0 D f I
Date:
Building Address:
Mailing Address (if different from building address):
Tenant Z (If tenant please provide a letter from the building owner approving the tenant improvement.)
Building Owner ❑
Are Hazardous Materials being used as part of this project? Yes El No
Tenant/Building Owner's Name:
Phone #:
�iog,.gl� •1 l�
M f Ss
Contractor:
DICKI�So
Phone #: 7(vo q3$ 9111
Cr4wl Co i .
Fax #:
Cupertino Business License: State Contractor License #:
32-1 *7 Z_ Colo Z. 3
Contact:
&1,44 pmscS od%
Phone #: q) S - 3& 3 • S.,,:S
Fax /e-mail:
Landscape Ordinance Compliance:
Landscape area in sq. ft. (includes all irrigated areas):
If 2,500 sq. ft. or less, compliance with the Landscape Water -Efficiency Checklist is required.
If more than 2,500 sq. ft., a complete Landscape Project Submittal is required.
Compliance Method: ❑ Plant Type ❑ Water Budget
Job Description (be specific):
MOaK, u P or 4/.1 RPAcF A rAtL S7U C
�,Y 1 S7-/AJ67 LE*qSI< CPJC.E 6,000
Tenant Improvement Includes Re -Roof: Yes ❑ No 5�1 If yes, number of squares
Tenant Improvement Includes Structural Yes c No ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B IMII/V-A ❑ II/III B, IV -HT, V-B ❑
Valuation: So oot,->
Project Size: Counter 0 Express Standard 0 Large Major
Green Building: Please complete Leed for commercial interiors checklist & attach it to the application
or if applicable, include in plans & sheet index
LEED Points Achieved
* * * For Office Use Only*** Revised 12-06-10
Building Department
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: D
PERMIT # / 2
OWNER'S NAME:
PHONE #
GENERAL CONTRACTOR: 04mEAggj
BUSINESS LICENSE # Z 1 2
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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: �' z—A i
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
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