B-2016-1270CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1270
10050 N WOLFE RD CUPERTINO, CA 95014-2521 (316 20 086)
(PACIFIC PLUMBING &
SEWER SERVICE INC)
NULPITAS, CA 95035
OWNER'S NAME: I&G DIRECT REAL ESTATE 27 LP
DATE ISSUED: 01/27/2016
OWNER'S PHONE: 4089828407
PHONE NO: 4088949120
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class-3C 6.A.B Lic. #745976
Contractor (PACIFIC PLUMBING & SEWER SERVICEINC 1 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 N-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
performance of the work for which this permit is issued.
••a 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
Sq. Ft Floor Area:
Valuation: $1200.00
this permit is issued.
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
316
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 WORK 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 LAST CAL INSPECTION.
Code, Section 9.18.
/ �
�
/ ���Date
Issued b MELISSA NAMES
,�//%%
Signatur.2 01/27/2016
Date: 01/27/2016
L
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).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury one of the following three 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
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
s. 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
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
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,tSections 25505, 25533, an 25534.
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
�� 'mss
Owner or authorised agent L/l/GG
be deemed revoked.
Date: 01/27/2016
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
CUPERTINO
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 MISC
(408) 777-3228 • FAX (408) 777-3333 • building
C�cupertino.orcl
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U PLUMBING LJ MECHANICAL. LJ i;i n� i u. n, u ••••�• .. - -- --
APN # 3 16 - z e) - o g �
PROJECT ADDRESS t00 G (�.. f ^n ��
J 0 WOLK
MAIL
OWNER NAME .
ONE U V D �lO� �e l Q1 I Y l L11STREET
FAX
ADDRESS �S-rST• % TAT O �� CA -
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CONTACT NAME j�� I I j� j/y� �r , l PHONE % ( _ Q� 61 E-MAIL
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CITY, STATE, ZIP FAX
STREET ADDRESS
❑ OWNER ❑ OWNER -BUILDER ❑OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑;DEVELOPER ❑TENANTCODITRACTORNAME`,'
j-LICENSENUMBER�(4q�] f LICENSE TYPE
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BUS. L���
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COMPANY NAME 1 r � �1`^4 ^ E-MAIL j6ScFAX
'� Z
STREET ADDRESS
CITY, STATE, ZIP 1 C45 •
PHONE Z�
ARCHITECT/ENGINEER NAME {� / f�
Y
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY
PROJECT IN W ILDLAND ❑ YES
PROJECT IN ❑ YES
❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
BUILDING: ❑ COMMERCIAL
URBAN INTERFACE AREA ❑ NO
FLOOD ZONE
DESCRIPTION OF WORK
TOTAL VALUATION: 0 /100
By my signature below, I certify to each of the following: I am the property owner or authorized a act on the property�bcha ave read this
and the information I have provided is correct I have read'the Description of Work and verify it is accurate. I agree to comply with all applicable local
application
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identi ed property for inspection purposes.
007 Date:
Signature of Applicant/Agent:
S LEMENTAL INFORMATION REQUIRED 2 % z (OFFICE USEONLY F= f' '' x-
ER THE -COUNTER;'
W n
❑x�EXP1iESS , r�
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FV___W07 FFF FSTIMATOR — RIJILDING DIVISION
ADDRESS: 10050 N WOLFE RD
im,
DATE: 01/27/2016
REVIEWED BY: MELISSA
APN: 316 20 086
BP#: B-2016-1270
*VALUATION: 1$1,200
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
USE: Commercial Building
Plumbing
IPCSEWER Sewer, Sanitary
PENTAMATION
PERMIT TYPE: 1 CPS A
WORK
INSTALL N PROPERTY LINE CLEANOUT
SCOPE
$0.00
Plumb. Plan Check 10.0 1 hrs $0.00 I`•Ie,,%• I'lon i.a(C C
Plumb. Permit Fee: 1PPERMIT t'i'c, I's t ia'f Fee:
Other Plumb Insp. 10.0 1 hrs 1 $48.00 t112v. ij,,,sl7.
Ali till. In J1. i`e e:
i?'sp. Vee:
771
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Mvirirt_ air ) Thaca faav ara hacad nn tha nreliminary information available and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/132
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
0 #
$25.00
Plumbing
IPCSEWER Sewer, Sanitary
Suppl. PC Fee: 0 Reg. 0 OT
0.0
hrs
$0.00
PME Plan•Check:
$0.00
Permit Fee: _
$0.00
Suppl. Insp. Fee:Q Reg. Q OT0
0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$48.00
(1(11J:1&Ucl ion :litFT
Administrative Fee:
(ADMIN
$45.00
0
`"
Work Without Permit? 0 Yes@ No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
iB,uilding or Structure
G)
0
i
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee:
IBSEISMICO
$0.50
Select an Administrative Item
Bldg_Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:,
$142.50
$25.00
TOTAL FEE;
$167.50
Revised: 01/01/2016