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10110145I CITY OF CUPERTINO BUILDING PERMIT I I BUILDING ADDRESS: 10129 S DE ANZA BLVD I CONTRACTOR: , &* ^LTcr'"en � PERMIT NO: 10 110 145 1 OWNER'S NAME: 1 -.7`/ i9i'l7li /v+// if,))I7,o LATHONENO: I ❑ 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). 1 I hereby affirm under penalty of perjury one of the following three I` 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. Signature Date 1 BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB r— MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: I LOVE BENTO - COM'L TI - ADD KITCHEN EQUIPMENT WITH TYPE I HOOD, PREPARATION SINK(FLOOR SINK),GREASE TRAP FOR POT SINK,NO ELECTRICAL Sq. Ft Floor Area: Valuation: $15000 APN Number: 35910015.10129 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by 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 1 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. Own or a rized agent: I Date• l 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 Add ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO Fm--7 FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10129 s. de anza blvd. DATE: 11/19/2010 REVIEWED BY: bobs. APN: BP#: 'VALUATION: 1$15,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: Commercial Building 11_ �..100R <IRE,1: PENTAMATION PERMIT TYPE: 1 B TI WORK add kitchen equipment includes type 1 hood fryer, broiler, oven refrigeration unit sink make-up iair SCOPE register. non structural, no lighting, no additional electrical or plumbing work. OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,III-B,IV,v-B 0 $0.00 $0.00 TOTALS: 0 $0.00 x;,;r`=s='t=:r,5r; $0.00 1 <.• h , 1 .y �Ytt r.��z� �5�sa..,..t...s.. r>.:�,f..t`.i•'rx,�i Mech. Plan Check 1.0 hrs $126.00 6,{ .: �'`'+::xt:::........... �•r�; ,:.<....,�..:-�;r�.. �,.. Plumb. Plan Check 1.0 hrs r '�y� �' �;.•1.,, .?y',... •�:,.. ON IMECPLNC Mech. Permit Fee: 11PERMIT IPLMBLNC I Plumb. Permit Fee: IPPERMIT Other Mech. Insp. 0.0 hrs $42.00 Other Plumb Insp. 0.0 hrs-r:.r.<r ., .. t.;, ..Li NOTE: These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 09-051 E . 7/1110) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # $126.00 Mechanical IMCHOOD Hood, Mech. Exhaust Suppl. PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $252.00 ® # $252.00 Mechanical /BAPPLOT Other Appliance/Equip Permit Fee: $0.00 Suppl. Insp. Fee-.0 Reg. 0 OT 0.0 hrs $0.00 0 # Mechanical $126.00 IMCRAA Refrigeration Unit PME Unit Fee: $0.00 PME Permit Fee: $84.00 1 # $32.00 Plumbing IBPINTERCE Interceptor, Ind. Waste Construction Tax -77 Acoustical Fee: 0 Yes 0 No $0.00 0 # $42.00 Plumbing IPREPPIPE Piping, Drainage 0 Work Without Permit? 0 Yes 0 No $0.00 Plannin Fee: $0.00 Select a Non -Residential Building or Structure 0 i Travel Documentation Fee: 1TRAVDOC $42.00 Strong Motion Fee: IBSEISMICO $3.15 Select an Administrative Item Bldjz Stds Commission Fee: IBCBSC $1.00 t{ .f � r, y •.3•t �••' .- irs 382. 15 8. 960. 5 Revised: 11 /08/2010