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150300970 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10201 TORRE AVE CONTRACTOR: SOUTHLAND PERMIT NO: 15030097 INDUSTRIES OWNER'S NAME: I & G DIRECT REAL ESTATE 21 LP 33225 WESTERN AVE DATE ISSUED: 06/10/2015 OWNER'S PHONE: 4087906400 UNION CITY, CA 94587 PHONE NO: (510) 477-3300 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL F] COMMERCIAL LAB 126 - INSTALL 2 (N) ROOF TOP COOLING UNITS License Class Lic. # % 4/ 410 REV # 1 - STRUCTURAL DETAIL FOR FAN COIL UNIT - Contractor `5c,u*1/111 d/ .mac:( Date 1' — /6-- / S— ISSUED 7/16/15 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: $150000 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 permit is issued. APN Number: 36941005.00 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 WITIIIN 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 FROMLAST- - _ 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 / granting of this permit. Additionally, the applicant understands and will comply Iss — Date: f with all non -point source regulations per the Cupertino Municipal Code, Section RE 9.18. Signature � � Date ��1� ^ /� -ROOFS: All roofs shall be in pected prior to any roofing material being installed. If a roof is installed without fust obtaining an inspection, I agree to remove all new materials for inspection. ElOWNER-BUILDERDECLARATION 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 ._505, 25533, and 2553 . Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized ager.. / 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 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 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 ❑ NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION ))r, COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingCftupertino.org ' ❑ ADDITION ❑ALTERATION / TI � REVISION / DEFERRED ORIGINAL PERMIT ®® �— PROJECT ADDRESS 109 09 I .._.. _, \ Il J\ +APN R �j p 005 P OWNERNAME. `` rrPH N$ C E-MAIL h 't Gni STREET ADDRESS CITY, STATE, ZIP I FAX CONTACT NAMEr 8 0 i IL rE-M STREET ADDRESS CITY, STATE, ZIP FAX OWNER ❑. OWNER -BUILDER ❑ OAWERAGEN•r ❑ CONTRACTOR - ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRA LICENSE T MA �.05'kr \ S IC /A)LA Olvf!P NAD E 4 E-MAIL FAX SIRE T ADDRESS CITY, ST TE, ZIP PHONE a ARCHITECT/ENGINEER NAME -- LICENSE NUMBER B^US, LIC O COMPANY N E-MAIL AVitG'l E Gd, '•l 1 S } i (C� FAX STP.EET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK .�`' _ ++ WOK ��rr /` �`^ / -��,(' ,, �^' y 1 -- �Y AIIWOK 416��i� fCA d .J�ft� ''h'l��d Co6� , (Jf\"k- 1 d Eh3STINGUSE PROPOSED USE CONSTRTYPE ISTORIFS I USE TYPE OCC. I SQ.FT. VALUATION (S) =TG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA ._ BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA I TOTAL DECK/PORCH AREA GARAGE AREA: EIDETACH ❑ ATTACH m D ATLLIXGUNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑YES BEING ADDED? No ADDITION? EjNO er" PRE -APPLICATION ❑ YHS IF YES, PROVIDE COPY OF PLANNINGAPPLm ❑NO PLANNING APPROVAL LETTER IS THE BLDG]:] -Yin---- I EICHLERHOMfi? - y -. ' TOTAL VALUATION: � ln " By my signature below, I certify t eagh of the following: I am the property owner or aut1-gj agent e property owner s beh I have read this application and the information I,I Pave provided is collect, a dread the Description of \T z*,EM ver"dy fy it inaccurate. I agree to comply with al applicable local ordinances and state laws rel ng t it inQlc nstl ct'o I th ri(�e reprs ntajttiv/�es of Cupertino to enter the. v-identife prpperty i s e ion -purposes. �1 h�' SipatureofApplicant/Agent: t j:� ��y V Date: to SUPPLEMENTAL INFORMATION REQUIRED zy�P,omom' = ; Y New SFD or Multifamily d%vellings: Apply for demolition permit for � MOM- � ��� OYERHE COUNTER t ��BUILDGPI �a�TREVIE4Y " existing building(s). Demolition permit is required prior to issuance of building .�� F r E t permit for new building.# _ ExPFSs~� l �AhnnGEL�RFw E c.5,4 i rF ".�rCt y--.•..1 .5., 4 ~4.4 gh-5_c-.Ku '�`i�+".�'YS�$+•�`3' T'�e`' _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure sAnDRD1�, PZJSLT�oRx�� formL{�r if any Hazardous Materials are being used as part ofthis project. �? _ Copy of Planning Approval Letter or Meeting with Planning prior to am submittal of Building Permit application. KC1-•-.nx��IrItsRDzsrRtc BldgA,pp_2011.doc revised 06/21/11 CITY OF CUPERTINO ISI FFF. ESTIMATOR — BUILDING DIVISION im,ADDRESS: 10201 TORRE AVE DATE: 07/16/2015 REVIEWED BY: MELISSA APN: 369 41 005 BP#: 15030097 *VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: Commercial Building Civil / Religious activities in BQ zone? 0 Yes No PENTAMATION PERMIT TYPE: 1 GENCOM � WORK REV # 1 -STRUCTURAL DETAIL FOR FAN COIL UNIT- ISSUED 7/16/15 SCOPE rblech. Plan Check Plru)rh. Plan Check Llec:, Plan Chet% iLlac/r. Permit Fere: I I Plunsb. Nrnzi/ Fee: I tiles. Permit tee: Orher Aleck. Insp. .Neck. Insp. Fee: Other Plumb Inst). Phunb. 1 nsp. Fee: Other Elec. Insp. Eke. Insp. Fee: NOTE: This estimate does not includefees due to other Departments (i.e. Planning, Public worics, rare, aanirary newer utsrricr, acnaot nIM .. ! ., b.. ..d .._ fl.- nl:.,, Nf niinn nvni/nhlo a".4 aro njily as, o.Ctimam_ Cnntart the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E f 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 0 hours $143.00 Plan Check, Hourly ISTPLNCK Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. Fee -(F) Reg. Q OT 0,0 hes $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXC $0.00 Administrative Fee: E) Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential 0 Building or Structure 0 Trm,el Documenlation Fees: Strong Motion Fee: $0.00 1.0 hrs $143.00 Inspections ISTINSP Inspection, Hourly Bldg Stds Commission Fee: $0.00 gTAL.S .. SUBT. $0.00 $286.00 TOTAL FEE $286.00 Revised: 07/02/2015 P CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10201 TORRE AVE CONTRACTOR: SOUTHLAND PERMIT NO: 15030097 INDUSTRIES OWNER'S NAAfE: I & G DIRECT REAL ESTATE 21 LP 33225 WESTERN AVE DATE ISSUED: 06/10/2014 OWNER'S PHONE: 4087906400 UNiON CITY, CA 94587 PHONE NO: (510) 477-3300 JOB DESCRIPTION: RESIDENTIAL COMMERCIAL LICENSED CONTRACTOR'S DECLARATION LAB 126 - INSTALL 2 (N) ROOF TOP COOLING UNITS L1 `rr License Cl ��a's++s _ LA�ic�1.# ` Contractor�✓�Ylmlt'Y�o-DJate_l�IfrZ— I hereby af(irtu 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: 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. Sq. Ft Floor Area: Valuation: $150000 1 have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 36941005 00 Occupancy Type: Section 3700 ofthe Labor Code, fix the performance of the work for which this permit is issued. APPLICANT CERTIFICATION 1 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 180 DAYS FROM LAST CALLED INSPECTION. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless die City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the ' 'onally, Issued by: Date: granting f this permit. A tl a applicant understands and will comply with all n point source gu tions p r, the Cupertino Municipal Code, Section RE -ROOFS: 9 18. Signature Date 1 `7 All roofs shall be inspected prior to any roofing material being installed. if a roof is installed without first obtaining an inspection, 1 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 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) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSLiRE construct the project (Sce.7044, Business & Professions Code). I have read the hazardous materials requirements tinder Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. i will 1 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 die Labor Code, for the of the work for which this pennit is issued. air contaminants as defined by the Bay Area Air Q r lity Management District I will maintain compliance witt t he Cupertino Mu c}}tat Code, Chapter 9.12 and performance S Clint f l h & S Codc the eatSafety h 2.505,2553'' � I have and will maintain Worker's Compensation insurance, as provided for b}' y ' IjS 7 Section 3700 of the Labor Code, for the perfonmancc of the work for which this Owner or authorized agen �� Date. Yl permit is issued. 1 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 Li'sNDING AGENCY Compensation laws of California. If, after making this certificate of exenmption, 1 become subject to the Worker's Compensation provisions of the Labor Code, 1 must 1 hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deenmed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 1 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 CONSTRUCTION PERMIT APPLICATION 0P 12 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildincin cuDertino.org \ CUPERTIIVC? r� f1 _____ I� I .____...- •.... I� ,--Dun nvtl:T/.IAt PPPKAIT@ IJ NI N' GVN51 KUG11VN t_I AvvilRJ0v (�I n ,�,+ .. •• • .• �� •_ • • - -- - - -- PROJECT ADDRESS 10201 Torre Ave APN H /] 0 OWNER NAMELab126 �" ,r �.,lT I PHONE V1 408-790_-6400 E-MAIL STREET ADDRESS 10201 Torre Ave CITY, STATE, ZIP 5 014 Cupertino,C A 9 FAX `,_` _ ^� ^� CONTACT NAME PHON P � � + S4A L iQd `/ STREET ADDRESR - _ _ CITY, STATE, ZIP FAX J2 -u e -r -t rl-o , �4� ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ® CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER 114040 LICENSE TYPE B BUS. LIC # 26446 COMPANY NAME Southland Industries L- MAIL ssaeed@southlandind. com FAX 510-475-9080 STREET ADDRESS 33225 Western Ave CITY, STATE ZIP Union City, CA 94587 PHONE 510-477-3300 ARCHITECTiENGINEER NAME LICENSE NUMBER 029313 BUS. LIC # 26446 Mark Edhammer COMPANY NAME Southland Industries E-MAIL FAX 510-475-9080 STREET ADDRESS 33225 Western Ave CITY, STATE, ZIP Union Cit CA 94587 PHONE5I O-477-3300 DESCRIPTION OF WORK Addition of cooling equipment - 2 condensing units on roof and 5 fan coils in building. No duct work to be added. EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION (3) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCFI AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ODETACH ❑ ATTAC H # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECONDSTORY OYES BEING ADDED? ONO ADDITION? ONO PRE -APPLICATION [-]YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES II E - p ! AL VALUATION: PLANNING APPLq ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO / .,,,..�' -f �,I i� i , 1 I�It I� r�lfll I i C� _) By my signature below, I certify t le ch of the following: I am the property owner or authorized ept to act on $lm --perry owner's behalf. 1 have read this is I have Description Work ve • s accurate. I agree to comply with all applicable local application and the information I av� provided correct. ad the of and ,i • ordinances and state laws relatin to buildin cons etion. I a ori a rcpresenta ies of Cupertino to enter the above -identified property for inspection purposes. � � Signature of Applicant/Agettt: Date: .. :. SUPPLEMENTAL INFOkMATIONREQUIRED il�{r't; ;s. `,'I,=,1►r,D , _ New SFD or Multifamily dwellings: Apply for demolition permit for 1U i OLERtI RE COUNTI R { '3 s t BU1LDINGIPLAN{REVIEW/ i existing building(s). Demolition permit is required prior to issuance of building (l�I permit for new building.�)I;ll �IIEAPRE59 1 �i '�; ` Ti �'❑�IIPI ANNINCIPI`ANIPEVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ��ill 51sTANUARD, , �r���tlirueirofwotiKs; _ forst if any Hazardous Materials are being used as part of this project. Copy of Planning Approval Letter or Meeting with Planning prior to `4r'�S LARGE � r' i�}�FIREIDEPTi ��irit` • l f} submittal of Building Permit application. f0, MAJOR 1 y i'.�.�SANITAIiYSEWER±DISTRICT ENYIRQNM ENTALH EALTHf% BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10201 TORRE AVE DATE: 03/16/2015 REVIEWED BY: MELISSA _ APN: 369 41 005 'VALUATION: Fi 15 0 00 0 .'PERMIT TYPE: Mechanical PermitPLAN CHECK TYPE': Alteration I Addition / Repair PRIMARY PENTAMAI FURN/AC USE: Commercial Building PERMIT TYPE: WORK INSTALL 2 (N) ROOF TOP COOLING UNITS SCOPE APPLIANCE EQUIP TYPE FEE ID I I I QTY UNITS BP FEES Cooling Unit 1MCRAA 2 # $286 $48.00Lj L_ ii f t 7.)).. 1 i c _y_ =__ k1-- Wct,­ipt PME Unit Fee: $286.00 PME Permit Fee: $48.00 Administrative Fee: I/fDjWIN $45.00 Work Without Permit? 0 Yes Q) No $0.00 7 TOTALS: Travel Documentation Fee: 1TllrfvDOC $48.00 Strong Motion Fee: IBSEIStIlIC0 286.00 $ Select an Administrative Item NOTE: This estimate does not inewalefees nue ro ower.....•.. 6 , , "., -.. -If; __ I __ __ - ,tl,, none ff)r addii'l info. District, etc.). These jee-v are Dasea on rize preummur") FEE ITEMS (&e Resolution 11-0 3 Ell. 711113) y I I I MISC ITEMS Mech. Plan Check 0.0 hrs $0.00 Mech. Permit Fee: IjWPERXf1T PME Plan Check: Other Mech. Insp. _E] �hrs Lot $48.00Lj L_ ii f t 7.)).. 1 i c _y_ =__ k1-- Wct,­ipt NOTE: This estimate does not inewalefees nue ro ower.....•.. 6 , , "., -.. -If; __ I __ __ - ,tl,, none ff)r addii'l info. District, etc.). These jee-v are Dasea on rize preummur") FEE ITEMS (&e Resolution 11-0 3 Ell. 711113) Illjull,lf, lull 11 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 f PME Unit Fee: $286.00 PME Permit Fee: $48.00 Administrative Fee: I/fDjWIN $45.00 Work Without Permit? 0 Yes Q) No $0.00 7 A Travel Documentation Fee: 1TllrfvDOC $48.00 Strong Motion Fee: IBSEIStIlIC0 $42.00 Select an Administrative Item Bldg~ Stds Coninjission Fee: I 13CBSC $6.00 . . .. .. ....... uiv, $475.00 $0.00 $475.0075.0 M U V I b t: U . u/ , I Yj L U IJ CITY OF CUPERTINO BUILDING PERMIT • BUILDING ADDRESS: 10201 TORRE AVE CONTRACTOR: SOUTHLAND PERMIT NO: 15030097 INDUSTRIES OWNER'S NAME: I & G DIRECT REAL ESTATE 21 LP 33225 WESTERN AVE DATE ISSUED: 06/10/2015 OWNER'S PHONE: 4087906400 UNION CITY, CA 94587 PHONE NO: (510) 477-3300 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ LAB 126 - INSTALL 2 (N) ROOF TOP COOLING UNITS REV # 1 - STRUCTURAL DETAIL FOR FAN COIL UNIT - License Class Lic. # DEFERRED #1 - CONDENSATE PIPING - ISSUED 9/10/2015 � � � 0 I 1 b 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. Sq. Ft Floor Area: Valuation: $ 150000 I hereby affirm under penalty of perjury one of the following two declarations: t. I have and will maintain a certificate of consent to self -insure for Worker's APN Number: 36941005.00 Occupancy T pe: Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. 1 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 EXPIRES IF WORK IS NOT STARTED permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INS C ION. 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 f ,t r Q t 0/00 40-J upon the above mentioned property for inspection purposes. (We) agree to save Issued by:*A6 Date: V indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expens s which may acc gainst said City in consequence of the granting of this it. Additional) applicantunderstands and will comply with ROOFS: all non -point sou regu ions per a upertino unicipal Cod , Section 9.18. All roofs shall be inspected prior to any roofing material being installed. If a roof is y roofing �� �I 1 � installed without first obtaining an inspection, I agree to remove all new materials for Signature Date inspection. Signature of Applicant: Date: —+ ❑ ER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER the following two reasons: t. 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 HAZARDOUS MATERIALS DISCLOSURE sale (Sec.7044, Business & Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2. I, as owner of the property, am exclusively contracting with licensed contractors to California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain construct the project (Sec.7044, Business & Professions Code). compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. I hereby affirm under penalty of perjury one of the following three declarations: Additionally, should I use equipment or devices which emit hazardous air t. I have and will maintain a Certificate of Consent to self -insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will Compensation, as provided for by Section 3700 of the Labor Code, for the maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sectio 25505, 2 533, and 25534. performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Owner nth ized ag Section 3700 of the Labor Code, for the performance of the work for which this Date: permit is issued. 3. 1 certify that in the performance of the work for which this permit is issued, I sh 11 CONSTRUCTION LENDING AGENCY not employ any person in any manner so as to become subject to the Worker's I hereby affirm that there is a construction lending agency for the performance of work's Compensation laws of California. If, after making this certificate of exemption, I for which this permit is issued (Sec. 3097, Civ C.) become subject to the Worker's Compensation provisions of the Labor Code, I Lender's Name must forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Address APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plans shall be used as public records. 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 Licensed Professional upon the above mentioned property for inspection purposes. (We) agree to save 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date gt.tst CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building ftupertino.orq CUPERTINO ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI REVISION /DEFERRED ORIGINAL PERMIT #) 0�) �� `3 PROTECT .ADDRESS M� ('� APN k I-„�CA r \ \ O R N ME , \ PHONE [� �, ^ �1 1� E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX _ �A /a/�i CONTACT NAMEC�k1,N,`(� l!`1` IIQ � 2� 1 '7 �F. IL��CIJ�� rl l 4113 STREET ADDRESS S3 � W l r• Q CUAT ZIP .�+� c� C fl FAX ❑ OWNER ❑ OWNER-BUIIAER 13OWNER AGENT ❑ CONTRACTOR 1:1CONTRACTOR AGENT 11ARCHITECT ❑ ENGINEER 1:1DE\TLOPER 13TENANT CONTRACTOR NAME�'"� _.. \A /� ww� %4� LIC EN B�L LICENSETYPF� BUS CQ#^ .S;� COMPANY�1 , w' lj \� E CjA FAX �Wn'np�pf`^ S � kN1 ZZ�ESS i1oiQr\ �QT 1'l� 1-3 AR jT1ENGINEEqAm4.,.,, �a A — LICENSE NUMB BUS. LIC;q COMPANY NAME R _I �t& CAL,( II aMAIL f I C FAX CkC �J\ Y2- � . � STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK. EXISTING USE PROPOSED USE CONSTR TYPE I I STORIES USE TYPE OCC. SQ FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH ARE I GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ONO ADDITION? ONO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES I VED BY: TOTAL V UATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO �'"�� ACAZ By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I h e read this application and the information I have p v ed is orrect. I have re the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatingXiltdico ction. 1 auth z represe fives of Cupertino to enter the abov identified property for inspection purposes. Signature of Applicant/Agent: Date: SUP P NTAL ORMATIO QUI D PLAN CHECK T]PE ROUTING SLIP OVER-THE-COUNTER El BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: App y for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANTING PLAN REVIEW. _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD STANDARD ` PUBLIC WORKS Form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT . _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEAT IR DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06121111 �1 F� ,�,�,, CITY OF CUPERTINO ,P, -//r1 FEE ESTIMATOR - BUILDING DIVISION:[hr imADDRESS: 10201 TORRE AVE DATE: 09/10/2015 REVIEWED BY: PAUL llech. I' APN: 369 41 005 BP#: 'VALUATION: $0 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial BuildingPENTAMATION USE: PERMIT TYPE: 1 GENCOM WORK DEFERRED #1 - CONDENSATE PIPING - ISSUED 9/10/2015 SCOPE NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, schooi District etc) These ees are based on the nrelimina information available and are only an estimate. Contact the Dept or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff.' %'1'13) 1fcch. flan Check l'Iumh. Plan Check Elec. Plan Check llech. I' Plumb. Permit Fee lilec- Permit Fee. Other .Ucc•h. /nup Other Plumb /rop Other 11Yec. Insp. st f I7 11asp. bee: Plumb. h:sp. Fee: 7 ", /-,�C NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, schooi District etc) These ees are based on the nrelimina information available and are only an estimate. Contact the Dept or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff.' %'1'13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # $286.00 Deferred Submittal IDEFSUBM Suppl. PC Fee: (F) Reg. Q OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? ()Yes Q No $0.00 Suppl. Insp. Feee. Reg. Q OT 0.0 J hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tar: .4drninistrative Fee: O E) Work Without Permit? Yes C) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential E) Building or Structure DI Travel Docuinentalicm Fees: Strong Motion Fee: $0.00 2.0 hrs $286.00 Inspections 1STINSP Inspection, Hourly Bidy_ Stds Commission Fee: $0.001 SUBTOTALS: $0.001 $572.00 TOTAL FEE: 1 $572.00 Revised: 07/02/2015