B-2016-1271 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1271
10080 N WOLFE RD CUPERTINO,CA 95014(316 20 086) (PACIFIC PLUMBING&
SEWER SERVICE INC)
MILPITAS,CA 95035
OWNER'S NAME: I&G DIRECT REAL ESTATE 27 LP DATE ISSUED:01/27/2016
OWNER'S PHONE:408-982-8407 PHONE NO:408-894-9120
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class -3C 6.A B Lic.#745976
Contractor(PACIFIC PLUMBING&SEWER SERVICE INC)Date 01/27/2016 X BLDG —ELECT X PLUMB
MECH RESIDENTIAL X COMMERCIAL
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. JOB DESCRIPTION:
INSTALL(I)PROPERTY LINE CLEANOUT
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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
p 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. Sq.Ft Floor Area: Valuation:$1200.00
APPLICANT CERTIFICATION
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 APN Number: Occupancy Type:
ordinances and state laws relating to building construction,and hereby 316 20 086
authorize representatives of this city to enter 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 PERMIT EXPIRES IF WORD IS NOT STARTED
expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will .
comply with all non-point source regulations per the Cupertino Municipal 180 DAYS FROM, PLED INSPECTION.
Code,Section 9.18. /,e�'��Date
' �� . Issued 1/2 MELISSAN
Signature C 01/27/2016 Date:01/27/2016
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1. I,as owner of the property,or my employees with wages as their sole inspection.
compensation,will do the work,and the structure is not intended or offered
for sale(Sec.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with licensed Date:01/27/2016
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. I bave 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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for California Health&Safety Code,Sections 25505,25533,and 25534. I will
by Section 3700 of the Labor Code,for the performance of the work for which maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
this permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 25505,25533,and 5534.
exemption,I become subject to the Worker's Compensation provisions of the
Labor Code,I must forthwith comply with such provisions or this permit shall
Owner or authorized agent: G
be deemed revoked. Date:01127/2016
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant ARCHITECT'S DECLARATION
understands and will comply with all non-point source regulations per the I understand my plans shall be used as public records.
Cupertino Municipal Code,Section 9.18.
Licensed
Professional
Signature Date 01/27/2016
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 MISC
(408)777-3228•FAX(408)777-3333•buildincA upertino.org /
PL ING []MECHANICAL. ❑ELECTRICAL MISCELLANEOUS .
PROJECT ADDRESS �,M`�, "N# B Z ®-F 6
OWNERNAMEl�_J� ..90 �'�.( _ PHONE 6� ("�O
E-MAIL
— cr
STREET ADDRESvS -� ST• 31 5 1� CITY,STAT, FAX
CONTACT NAME PHONE LftjQ!1 �(�61 E-MAIL
STREET ADDRESS �L F CITY,STATE,ZIP
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME #LICENSEUMBER- (45i r LNSE TYPE BUS.LIC#FAX
COMPANY NAME 1 � MAIL�6 STREET ADDRESS 3 �1 L (l .0 Y,STATE,ZIP 1 r PHONE -NZDARCHITECT/ENGINEERNAME ,1LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI FAMILY PROJECT IN WIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK 15( ,
�0
TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property owner or authorized agent on the s behalf. I have read d&
application and the information I have provided is correct. I have read the Description of Work and verify it is agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the abq e-dentifi9d property for inspection purposes.
Signature of Applicant/Agent: Date:� /I�^(/ /d
SUPPLEMENTAL INFORMATION REQUIRED `AFF�CEUEONL7CEs
a�v>�RF R&,PQ y
� 1'i�� ` v 'A'R`E$$x�',a✓ �`�� A ,i.
MEPMisc4pp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10080 N WOLFE RD DATE: 01/27/2016 REVIEWED BY: MELISSA
APN: 316 20 086 BP#: B-2016-1271 'VALUATION: 1$1,200
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1 CPSS�
WORK INSTALL N PROPERTY LINE CLEANOUT
SCOPE
tlech. 1'c<n(','heck Plumb.Plan Check 0.0 hrs $0.00 Is:<'ec;. .i'Jr.t;r t;?rc:c;l:
11scF?..1'e�;razr..f;e; Plumb.Permit Fee: IPPERMIT 1.tec.Peri:-a'fi"'e.
Other Plumb Insp. 0.0 hrs
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works,Fire,Sanitary Sewer District,School
District, etc. . Theseees are based on the reliminar information available and are onlyan estimate. Contact the De t or addn'l in o.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1� # Plumbing
Suppl. PC Fee: (j) Reg. 0 OT0.0 hrs $0.00 $25.00 IPCSEWER Sewer, Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:(F) Reg. Q OT 0:0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $48.00
consiruclion
Administrative Fee: IADMIN $45.00
Work Without Permit? Yes (2) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fee: ITRAVDOC $48.00 Building or Structure
i
Strong Motion Fee: IBSEISMICO $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00 7
SUBTOTALS: $142.50 $25.00 , TOTAL FEE;, $167.50
Revised: 01/01/2016