15070108CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19800 VALLCO PKWY
CONTRACTOR: LAYTON
PERMIT NO: 15070108
CONSTRUCTION
OWNER'S NAME: CUPERTINO PROPERTY DEVELOP LLC
9090 S SANDY PKWY
DATE ISSUED: 07/15/2015
OWNER'S PHONE: 4083431088
SANDY, UT 84070
PHONE NO: (949) 429-6740
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
GAS METER RELEASE REQUIRED PER PG&E FOR GAS
License Class Lic. # kf g
LEAK
Contractor r Date /
REPAIR. (ROSEBOWL)
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
Sq. Ft Floor Area:
Valuation: $�00
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
APN Number: 31620108.19800
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 T ED 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
Issued by: Date: /S
granting of this permit. Additionally, the applicant understands and will com
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature 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
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)
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(x) 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
Section 3700 of the Labor Code, for the performance of the work for which this
the Health & Safety Code, Sections 5, 25533 d 25534.
Date:
Owner or authorized agent:
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 • buildino(c1cupertino.org an --L /,%a W I I S C
CUPERTINO 7-U /O�
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PROJECT ADDRESS
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❑ O'1N`ER ❑ OR'NER-BUILDER ❑ OWNER AGENT
CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGI2\EER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE N MBER LICENSE TY E
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ARCHITECTIENGINEER NAME
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USE OF ❑ SFD or DUPLEX ❑ MULTI-FAI,-ELY
PROTECT IN WII-DLAND ❑ YES PROJECT IN ❑ YES
IS THE BLDG AN ❑ YES
BLMDAG: ❑ COMMERCIAL
URBAN LNITERFACE AREA ❑ NO FLOOD ZONE ❑ NO
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION: /�j�
By my signature below, I certify to each the following: I am the property owner or authorized agent act on the prop o is behalf. I have read this
application and the information I e ro ided is correct IrhavTe Description ofWork and verify it is accurate ee to comply with all applicable local
ordinances and state laws relating o i ing ion. presentatives of Cupertino to enter the above -id tified for inspection purposes.
property
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Signature of Applicant/Agent:
Date: l L�
PLEMENTAL INTORMATION REQUIRED
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MEPMiscApp_201 ].doe remised 06/21/11
f��CITY OF CUPERTINO
ip' -w FEE ESTIMATOR - BUILDING DIVISION
APPLIANCE / EQUIP TYPE
19800 VALLCO PKWY
DATE: 07/15/2015
REVIEWED BY: MELISSA
UNITS
APN91ADDRESS:
: 316 20 108
BP#: !
"VALUATION: $500
PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: Commercial Building
$72
PENTAMATION
PERMIT TYPE: 1 CPGA
WORK
GAS METER RELEASE REQUIRED PER PG&E FOR GAS LEAK REPAIR. ROSEBOWL
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00 Y/an Check
QTY
UNITS
BP FEES
Other Plumb Insp. TO.0 hrs $48.00 Other Elec. Insp.
Piping, Gas <=4 Outlets
1PGASRES
1
#
$72
Permit Fee:
Suppl. Insp Fee
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? O Yes Q No
$0.00
TOTALS:
F
Travel Documentation Fee: 1TRAVDOC
$72.00
Strong Motion Fee: IBSEISMICO
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
Th.— foot nro bacod nn tho nroliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 711113)
FEE
Plumb. Plan Check 0.0 1 hrs $0.00 Y/an Check
!Ltech. Per,;
Plumb. Permit Fee: IPPERMIT lilec. Permi-
Other A4ech. Insp.
Other Plumb Insp. TO.0 hrs $48.00 Other Elec. Insp.
Mech. Insp- Fee:
/Ilumh. hasp, Fee: Elec. Insp. Fee.
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
Th.— foot nro bacod nn tho nroliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E . 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
P1vIE Plan Check:
$0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? O Yes Q No
$0.00
Advuaiced Planning Fees:
Travel Documentation Fee: 1TRAVDOC
$48.00
Strong Motion Fee: IBSEISMICO
$0.50
Select an Administrative Item
131da Stds Commission Fee.: IBCBSC
$1.00
F- SUBTOTALS:
$214.50
$0.00 TOTAL FEE:
$214.50
Revised: 07/02/2015