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10060016 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21265 STEVENS CREEK BLVD STE 201 CONTRACTOR:GREENBERG CLARK INC PERMIT NO: 10060016 DB,�THE VNER'S NAME: JAMBA JUICE 4 600 BROADWAY STE C DATE ISSUED:06/03/2010 OWNER'S PHONE: 5596587900 SAt:RAMENTO,CA 95818 PHONE NO:(916)455-4433 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class L 3 Lic.# -7---1 Q MECH RESIDENTIAL COMMERCIAL Contractor-Olt-/ -L��f �� Date_,�L,3 � JOB DESCRIPTION: SEWER LINE REPAIR INTERIOR ONLY.WORK WITH NO I hereby affirm that I am licensed under the provisions of Chapter 9 PEI-MIT DOUBLE FEES. (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: 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 q. Ft Floor Area: Valuation:$7500 Section 3700 of the Labor Code,for the performance of the work for which thi permit is issued. AF N Number:32627035.201 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Addition the applicant understands and will comply with all non-point s ce reg ions per the Cupertino Municipal Code,Section 9.18. ,) Is:;ued by: Date: iat re Date w ❑ OWNER-BUILDER DECLARATION RE-ROOFS: Al I roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of in;talled without first obtaining an inspection,I agree to remove all new materials for the following two reasons: in;pection. 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, Si nature of Applicant: Date: Business&Professions Code) — 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I lave read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. ci impliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by S ifety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. n aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall H ealth&Safety Code,Sections 25505,25533,and 25534. 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 C authorized agent_ j become subject to the Worker's Compensation provisions of the Labor Code,I must wner Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is f)r which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating I ender's Name to building construction,and hereby authorize representatives of this city to enter the above mentioned property for inspection purposes.(We)agree to save bender's Address _„mnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 32627035 .201 DATE ISSUED. . . . . . . : 06/03/2010 RECEIPT # . . . . . . . . . BSOOOC10552 REFERENCE ID # 10060C16 SITE ADDRESS 21265 STEVENS CREEK BLVD STE 2 SUBDIVISION . . . . . . . CITY CUPER-INO IMPACT AREA . . . . . . OWNER JAMBA JUICE 4 ADDRESS 6475 CHRISTIE AVE STE 150 CITY/STATE/ZIP EMERY'TILLE, CA 94608 RECEIVED FROM THE T:ZENCHLESS COMP CONTRACTOR MAX G:ZEENBERG LIC # 31798 COMPANY GREEN3ERG CLARK INC DBA THE ADDRESS . 600 BZOADWAY STE C CITY/STATE/ZIP SACRAMENTO, CA 95818 TELEPHONE (916) 455-4433 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- - 1BCBSC VALUATION 7, 500 . 00 1 . 00 0 .00 1 . 00 0 . 00 1BSEISMICO VALUATION 7, 500 . 00 1 .68 0 .00 1. 68 0 . 00 1PCSEWER UNITS 1 . 00 42 . 00 0 .00 42 . 00 0 . 00 1PPERMITFE FLAT RATE 1 . 00 84 . 00 0 . 00 84 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 - - 0_00 ---- ------ ---------- ---------- TOTAL PERMIT 170 .68 0 . 00 170 . 68 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - ------------------- CREDIT CARD 170 .68 003545 --------------- TOTAL RECEIPT 170 . 68 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 507 FINAL PLUMBING a- 11 CITY OF CUPERTINO t-t11--1 REPIPE/SEWER[WAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN # Date: Building Address: �l C'2C--cU L) 4k- aoc Owner's Name: Phone #: 55`7 - 6549-•-7 f7 ContractorPhone#: -i/6 • q5'S- 9"(33 Fly T12r7vGyGC s Co Fax #: e?r 6 • 4(5-1-/ • 1l65- Contact: r Phone#: cr ` Yj3• Fax #: Contractor License#: -2-7.S`7 03 Cupertino Business License#: 3 11 '� g Job Description: n kh� l(� Residential ❑ C)mmercial Valuation: -75- 00 , dG Project Size: Express Standard, Large Major Green Building: Please complete `relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set& the sheet index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary sew er 1BPREPIPE Commercial re-piF a per fixture P 1CPRP 1 PGASCOM Commercial Gas F iping System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY Of CITY OF CUPERTINO 13 REPIPE/SEWER/?4AIN SERVICE FEE SCHEDULE CUPERTINO Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary sewe 1 PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool P 1BPWATER Install/alter Water Fipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets 1 BPGAS Gas Piping System 5+ Outlets P 1PPERMITFEE Plumbing Permit Foe Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/ga; Insp. P 1 TRAVDOC Travel &Documer.tation Fee B 1BUSLIC Business License B