14030172 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10150 N WOLFE RD CONTRACTOR:GREG BELLOWS PERMIT NO: 14030172
PLUMBING INC
OWNER'S NAME: J C PENNEY PROPERTIES INC 2652 RESEARCH PARK DR DATE ISSUED:03/31/2014
OWNER'S PHONE: 8314777150 SOQUEL,CA 95073 PHONE NO:(831)477-7150
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E]
JCPENNY'S-SEWER LATERAL SPOT REPAIR TO 4'
License Class C3 Lic.# �S�SFs // SECTION OF LINE
Contractor 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. Sq.Ft Floor Area: Valuation:$8400
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:31620094 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 WIT
�IIN 1 DAYS OF PERMIT ISSU CE 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' AY M LAST CALLED INSP C ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued b 'e Da /
granting of this permit. Additionally,the applicant understands and will comply y'
with all non-point source regulations per the Cupertino Municipal Code,Section
918.
RE-ROOFS:
Signature Date �l 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)
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 Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. /
Section 3700 of the Labor Code,for the performance of the work for which this 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 CONSTRUCTION LENDING AGENCY
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 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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify 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
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �\
(408) 777-3228•FAX(408)777-3333•building(a)-cupertino.org �� MISC
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PLUMBING [:]MECHANICAL —]ELF []MISCELLANEOUS
PROJECT ADDRESS \ t Ol`�ry� • 1.. �� APN#
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❑ OWNER _❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCH MCf ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME, v C `�� LICENSE NUMBER LICENSE TYPE BUS.LIC#
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STREET ADDRESS Y,STATE,ZIP PHONE
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USE OF ❑SFD or DUPLEX 13MULTI-FAMILY PROJECT IN WILDLAND ElYES TILIOD ROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING• � IN
ONMERCIAL URBAN TERFACE AREA ONO ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK (� I
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TOTAL VALUATION: �� �'
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act o e property ov is be al£ I have read this
application and the information I have provided is.correct. I have read the Description of Work and verify it is accurate— with all applicable local
ordinances and state laws relating to building cons do ropr5Qtatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: - 7 Date: Nam
SUPPLEMENTAL INFORMATION REQUIRED _ oFF1cE trsEbn>$ 4_
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_- - 215
MEPMisctlpp_2011.doc revised 06/11111
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10150 n wolfe rd DATE: 03/31/2014 REVIEWED BY: Mendez
APN: BP#: "VALUATION: $8,400
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY PENTAMATION 1 CPSS
USE: Commercial Building PERMIT TYPE: i
WORK c enn 's -sewer laterals of repair to 4' section of line
SCOPE
y Plumb.Plan Check0.0 hr's $0.00
'CIt !'.c7rt C ti cY,
Permit lia Plumb.Permit Fee: IPPERMIT
C�'tlrer ,lCt c 1. Cr�<<C>, Other Plumb Insp. 0.0 hrs $47.00 o lie ts'icc.Crs�.
1f ch. L,sv_f.:e Pluii0. hasp.Fee: I iec. Cusp tae:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E f 7/1/131 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl. PC Fee: Q Reg. ® OT 0.0 hrs $0.00 $24.00 IPCSEWER Sewer, Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. ® OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $47.00
C Con7t ti
t.acl},7 7_,a,\%'
Administrative Fee: IADMIN $44.00
Work Without Permit? ® Yes 0 No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Building or Structure 0
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: IBSEISMICO $1.76 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
x $140.76 $24.00 TOTAL FEE: $164.76
Revised: 01/15/2014