10120026I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: I0450 BUBB RD I C CONTRACTOR:
CONSTRUCTCOT ON CO I PERMIT NO: 10120026
MERO
I OWNER'S NAME: MISSION WEST 16184 INNOVATION WAY I DATE ISSUED: 12/06/2010 1
I OWNER'S PHONE: 4088624691 I CARLSBAD, CA 92009 1 PHONE NO: (760) 438-9114 1
❑ LICENSED CONTRACTOR'S DECLARATION
License Class 16 Lic. N L 9/--:� 2- Z
Contractor QAS gSs oglah Date
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 'rbs
permit is issued.
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 non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signat 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).
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
1 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.
r r- r
BUILDING PERMIT INFO: BLDG ELECT PLUMB r—
MECH I RESIDENTIAL I COMMERCIAL
JOB DESCRIPTION: INTERIOR DEMO 10,000 SQ Ff DEMO WALL & CEILING
NON-STRUCTURAL
Sq. Ft Floor Area: Valuation: $10000
APN Number: 35720037.10450 Occupancy Type:
PERMIT EXPIRES ]IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued Date: �2
RE -ROOFS:
Al I 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, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized ag`pt_ Date: %Z-l—, /p
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
Signature
Date
DEMOLITION
IM-
CITY OF CUPERTINO
I FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10450 bubb rd.
DATE: 12/06/2010
REVIEWED BY: bob s.
APN:
BP#:
"VALUATION:
j$10,000
*PERMIT TYPE: Demolition Permit
PLA'.'. CHECK TYPE:
PRIMARY SFD or DuplexL
USE:
PENTAMATION -YS'FOWL-DEM
PERMIT TYPE:
WORK
demo comm offices ace non structural.
SCOPE
FEE ID FLR AREA
s.f.
1 DEMORES 10,000
Wcch. l'hin Ch.<-,.k
I'hw�
F'rr�adrdF(w,
other , 4"!h. Insp.
U"'fik- • !''Iw'!i;
Ulho Ll
Fcc.
t°tumh.
Eke . h' p.
NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 09-051 E . 711110)
FEE
QTY/FEE
MISC ITEMS
Plum Check Fore:
Suppl. PC Fc c
Pla+�nh.%Rlcch.:Tlcc Plan Check -
Permit Fee:
Suppl. Insp. Fee-.0 Reg. 0 OT
0.0
hrs
$0.00
Plumh.iAdech.!Ilec Unit Fee:
Plumh.!!Wch./Elec Permit Fee.
Constrnclion Tax
lr:nt!s/icr.�l ReviewFee:
4"ork 11'ithout Pc i i'nit?
Planning Fees:
Travel Docom ntution Fco.s:
Strong Motion Fee: IBSEISMICR
$1.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
SUL`i'OTALS:
3B87-00
$0.00 TOTAL FEE:
ug'�-.00
(, 2 Revised: 11/08/2010
11 Zcv `l, / 0