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10030120 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21220 HOMESTEAD RD CONTRACTOR:TBD-TO BE PERMIT NO: 10030120 DETERMINED OWNER'S NAME: 7-ELEVEN DATE ISSUED:03/19/2010 WNER'S PHONE: PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIAL �►/CSr License Class Lic.# ���y��`� DEDICATED 110 VOLT 20 AMP CIRCUIT TO FRONT OF Contractor r�/f /��/� `' 1 Dae 17 '� STORE 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. Sq.Ft Floor Area: Valuation:$500 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. APN Number:32605086.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is 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: Date: with all non-point source regul ti per the Cupertino Municipal Code,Section 9.18. Y`/,� 3.f� /0 RE-ROOFS: Signat Dat 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 ElOWNER-BUILDERDECLARATION inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 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. I 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(a)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 Muni • al Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505 ,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this C; L permit is issued. Owner or authorized agent: Date: 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 Ripon the above mentioned property for inspection purposes.(We)agree to save lemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION .,sts,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 CITY OF CUPERTINO 5 ITEMS OF 9 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: B1k: Lot: APN . . . . . . . . : 32605086 . 00 DATE ISSUED. . . . . . . : 03/19/2010 RECEIPT #. . . . . . . . . : BS000009989 REFERENCE ID # . . . : 10030120 SITE ADDRESS 21220 HOMESTEAD RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER 7-ELEVEN ADDRESS P.O BOX 711 CITY/STATE/ZIP . . . : DALLAS, TX 75221 RECEIVED FROM . . . . : ALL CITY ELECTRIC CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 500 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BREMMISC FLAT RATE 1 . 00 126 . 00 0 . 00 126 . 00 0 . 00 1BSEISMICO VALUATION 500 . 00 0 . 63 0 .00 0 . 63 0 . 00 1BUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 283 . 63 0 . 00 283 . 63 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 453 .26 10413 --------------- TOTAL RECEIPT 453 .26 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 C U P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# OWNER'S NAME: /�f� L~JS:- >F,?� PHONE# 1;7-Cl -... /--1 . GENERAL CONTRACTOR: f / �, jP.G BUSINESS LICENSE# ADDRESS: / CITY/ZIPCODE: /S�i -64fll�" ZZ *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: 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 Date CITY OF 49 CITY OF CUPERTINO GENERAL BUILDING CUPERTIN© PERMIT APPLICATION FORM APN# Date: r Building Address: �21��� Mailing Address(if different from building address): Are Hazardous Materials being used as part of this project? Yes ❑ No ES HOA: Exterior work only) Yes ❑ No es, provide letter from HOA Ow,n 's re: Phone#• s,- Con tor: n,/ Phone: k / / ICL'���I�� Fax: Contractor License#: >' Cupertino Business License#: Contact �-fs►� Phone: Fax: Residential ❑ Commercial Job Description: ��-- Building Permit Info: .Bldg ❑ Elect � Plumb ❑ Mech ❑ Type of Construction(Usage Class): Occupancy Type: 1-A, 1-B El II/11IN-A ❑ II/VI B, IV-HT, V-B �� (& Valuation �o-. ._ Square Footage: Project Size: Express tandard ❑ 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.buildit Jreen.or s Revised 07/14/09 /03110 7-'4/;£. SIIRU_� CITY OF CUPERTINO CITY of GENERAL BUILDING APPLICATION CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) l EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone I 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B 1 BUSLIC Business License B 5 of 5 M.Indoor Air Quality and Finishes 1.Use Low/1I0-VOC Painf 1 IAD/Health pts y=yes p 2.Use Low VOC,Water-Based Wood Finishes 2 IAD/Health pts y=yes p 3.Use Low/No VOC Adhesives 3!AQ/Health pts y=yes p 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y--yes p 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQ/Health pts y=yes p S.Use Exterior Grade PlNr000d for Interior Uses 1 IAQ/Health pts y=yes p 7 Seal a1ADP3wdfk#bWebaaidr;,r MDF 4 IAD/Health pts Y=Yes p B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes p 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes p 1 D.Install Whole House Vacuum System 3 IAQ/Health pts y=yes p 1 1 N.Flooring 1 1.Select FSC Certified Wood Flooring B Resource pts y=yes p 2. Use f3aQi*Renewable Flooring Materials 4 Resource pts y=yes p 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes p 4.Install Natural Linoleum in Place of Vinyl 5[AG/Health pts y=yes p 5.Use Exposed Concrete as Finished Poor 4 Resource pts y=yes p S.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes p 1 1 1 Total Points Available: 140 130 57 Total Points Project Received: 0 01 0 //A G:data/progs/greenbuildinoauidelines/ramodalars/greenpoin:sfna1212D4proteeted.xls