10030119 Fax• 400-777-�'311
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21490 MC CLELLAN RD CONTRACTOR:TBD-TO BE PERMIT NO: 10030119
DETERMINED
OWNER'S NAME: 7-ELEVEN DATE ISSUED:03/19/2010
NNER'S PHONE: 8475463106 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class C1_ le, Lic.# ��'���� 110 VOLT 20 AMP DEDICATED CIRCUIT TO FRONT OF
Contractor
3 /,::�2 STORE
I hereby affirm that I am license 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 APN Number:36201027.00 Occupancy Type:
permit is issued.
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 regulatio pe upertino Municipal Code,Section
9.18.
_/(P1.ld RE-ROOFS:
Signat e Date 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
13OWNER-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
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 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 ' 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
permit is issued. Owner or authorized agegt: 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
-mon the above mentioned property for inspection purposes.(We)agree to save
:mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
.its,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
4 ITEMS OF 9 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36201027. 00
DATE ISSUED. . . . . . . : 03/19/2010
RECEIPT #. . . . . . . . . : BS000009989
REFERENCE ID # . . . : 10030119
SITE ADDRESS . . . . . : 21490 MC CLELLAN 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
1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 169.63 0 . 00 169 . 63 0 . 00
CITY OF
Ism
CITY OF CUPERTINO
GENERAL BUILDING
CUPERTINO PERMIT APPLICATION FORM
1CO3v ��
APN# �� C.) I U,-1. C)U Date:
Building Address: �"/V(70 -� r-'4-'e�� �
Mailing Address(if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
2 �
HOA: Exterior work only) Yes ❑ No If es, rovide letter from HOA •p �' J S
Owner's Name/ r ���, 1 /'1-'`i Phone#:
Contra / Phone:
f.C� Fax:
Contractor License#: �
Cupertino Business License#:
Contest: Phone: 7
Fax:
Residential Commercial ❑
Job Descri tion: �'�, ��J� ✓ / C ��% �i�-YrL / �--�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ 11/IIIN-A ❑ 11/III B, IV-HT, V-B FtY
Valuation: / — Square Footage:
Project Size: Ex ress tandard ❑ Lar e❑ 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 rreen.or j
Revised 07/14/09
l CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPE(�T1N0
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)
1 EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK 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
l' 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1 BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
1 BUSLIC Business License B
5 of 5
all
M.Indoor Air Quality and Finishes .
1.Use Low/�lo-VOC Paint 1 IAD/Health pts y=yes p
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes p
3.Use Low/W VOC Adhesives 3 IAD/Health pts y=yes p
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes p
6.Use Exterior Grade Plytr000d for Interior Uses 1 IAQ/Health pts y=yes p
7.Sed Id�,r tv9L�F 41AQ/Health Dts - es
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 0
10.Install Whole House Vacuum System 3 IAO/Health pts y=yes p
1 1
N.Fiaoring /
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
Z Use Rapidyflanev a-We Flooring Materials 4 Resource pts y=yes p
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes D
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes p
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
1 1 1
Total Points Available: 140
1301 571
Total Points Project Received: 0 01 0
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