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11010047 CITY OF CUPERTINO BUILDING PERMIT BUILDING AdDRESS: 10991 N DE ANZA BLVD CONTRACTOR:D R DOMENICHINI PERMIT NO: 11010047 CONSTRUCTION "WNER'S NAME: STAR ONE CREDIT UNION 1715 PINECREST DR DATE ISSUED:01/07/2011 WNER'S PHONE: 4085435125 SAN MARTIN,CA 95046 PHONE NO:(408)691-3283 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Lic.# 3 g INSTALLING NEW RECESSED OUTLETS TO POWER FLAT Contractor orne.0(Gh trri-t Date SCREEN TV DISPLAYS,OUTLETS IN 3 LOCTIONS, I hereby affirm that I am licensed under the provisions of Chapter 9 BEHIND (commencing with Section 7000)of Division 3 of the Business&Professions TELLER STATIONS,ADJACENT TO OFFICES,IN WAITING 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. Sq.Ft Floor Area: Valuation:$1591 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 APN Number:32610059.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above Jo PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by:- ��' ate: with all non- oint source regulations per the Cupertino Municipal Code,Section 9.18. r —7 RE-ROOFS: Cignature a `~ ( ^ (� 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. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,75533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this 'a _ Owner or authorized agent: Date: 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 -non the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION demnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: O�Z 6eP-nrj Z-A j3ZAJO PERMIT# 0 OWNER'S NAME: �kl SLS S'r* ox,-CPHONE# 57ct S- `125— GENERAL CONTRACTOR: �, a,rem ,t, ; BUSINESS LICENSE# ADDRESS: Q•0, $6K u-t 30 S n CITY/ZIPCODE: G � *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 AL SUBCONTRACTORS HAVE OB T NED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: i l S' nature Date Please check applicable subcontractors and complete the following information: V 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 Date CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 10991 de anza blvd DATE: 01/07/2011 REVIEWED BY: bobs. APN: BP#: *VALUATION: 1$1,591 FPERMIT TYPE: Electrical Permit PLAN C EC TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1REAP10 USE: I I PERMIT TYPE: WORK install 3 new outlets to power flat to displays. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Recep/Switch/Outlets 1BREMRECEP 3 # $42 TOTALS: $42.00 Afech. Plan Ch,r k I'huzrt> Phm C1recE771 Elec.Plan Check 0.0 hrs $0.00 14"ch. 11,,rmit Fc>e: 1,111n'b. Elcc.Permit Fee: IEPERMIT Oiliur.1kcA OlPcr himit"Ir�,.>_ Other Elea Insp. Eflhrs $42.00 11c<h. Iny, 1°ac_ PiliI)i1J 11s1;. F��, f i<c_IraC° NOTE: Thesefees are based on the preliminary in ormation available and are onI an estimate. Contact the De t or addn'1 info, FEE ITEMS (Fee Resohition 09-051 Eff. 711110) FEE QTY/FEE MISC ITEMS Plan ('he k f e: Suppl. I'(:'11-eC PME Plan Check: $0.00 Permit 1'e>t': suppl. Insp I-'ee PME Unit Fee: $42.00 PME Permit Fee: $42.00 C011S117rciion 1 LV acoustical Rc view 1-ee: Work Without Permit? 0 Yes (F) No $0.00 Plunnim) 1'e eco. Travel Documentation Fee: ITRA VDOC $42.00 A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $127.50 $0.00 TOTAL FEE: $127.50 Revised: 12/07/2010 CITY OF �O CITY OF CUPERTINO GENERAL BUILDING C U P E RT I N O PERMIT APPLICATION FORM APN# , �©J Date: Building Address: Mailing Address (if different from building address): Are Hazardous Materials being used as part of tbk project? Yes No HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA If Residential is house an Eichler? Yes ❑ N If es, needs planning approval. Owner's Name: Phone#: S� O s s '5113i- Contractor: Contractor: Phone: - G<, - 9 -z 63' P6 4 r G 'w a Fax: 01� - 6-4 - ti Contractor License#: s 3 �)536 Cupertino Business License#: Contact: Phone: k o v -2.:3 r - j -7 S C ate- Ci-,.-" W A. Fax/e-mail: -tr- 0 4z D Co vn Residential ❑ Commerc al [ Job Description: c S�4,7 S •• t'>�..t-t..t)'�S !� � �-tsc_r4�i O.v S•� I S.��, n7�. '�'-�.L.�~�-1s"f�4-i oN-` ; Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction(Usage Class): Occupancy Type: 5 1-A, 1-B Il/IIUV-A ❑ IUIII B, IV-HT, V-B ET""� $A---'J - ValuatSquare Footage: y 167J 0, ? �� Project Size: Counter Ex ress ❑ Standard ❑ - Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Points Achieved: For help, contact Build it Green at www.builditgreen.org Revised 12/06/10