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15090102CITY OF CUPERTINO BUILDING PERMIT CONTRACTOR: _ �;1 fF .PERMIT NO: 15090102 BUILDING ADDRESS: 10425 S DE ANZA BLVD OWNER'S NAME: BDC HAYWARD LP DATE ISSUED: 09/16/2015 OWNER'S PHONE: 9255882226 PHONE NO: l LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ License Class__ Lic. #_ j 2 S INSTALL TEMPORARY HALLOWEEN STORE IN (E)OCCUPANCY FOR LIMITED TIME PERIOD Contractor i-W�f!4L&Date 0-7fD 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: Sq. Ft Floor Area: Valuation: $5000 i. I have and will maintain a certificate of consent to self -insure for Worker's mpensation, as provided for by Section 3700 of the Labor Code, for the formance of the work for which this permit is issued. Up-lave APN Number: 35917019.10425 Occupancy Type: 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. PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR 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 180 DAYS FR INSPECTION. to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the Ci of Cupertino against liabilities, �udgm s, City Cu uedDate: 1 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 Cupertino p Municipal Code, Section 9.18. RE -ROOFS: Signature �a All roofs shall be inspected prior to any roofing material being installed. If a roof is Date_ __Zg („j installed without first obtaining an inspection, I agree to remove all new materials for T� inspection. Signature of Applicant: Date: ® OWNER -BUILDER DECLARATION 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. 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 2. I, as owner of the property, am exclusively contracting licensed I have read the hazardous materialsrequirements under Chapter 6.95 of the California Health with contractors to construct the project (Sec.7044, Business & Professions Code). & Safety Code, Sections 25505, 25533, and 25534. I will maintain 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 performance of the work for which this permit is issued. Health & Safety Code, Sections 25505, 25533, and 25534. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Owne ize Section 3700 of the Labor Code, for the performance of the work for which this , leo en Date:-� permit is issued. 3. 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 I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code, I for which this permit is issued (Sec. 3097, Civ C.) must forthwith comply with such provisions or this permit shall be deemed Lender's Name Lender's Address revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION correct. I agree to comply with all city and county ordinances and state laws relating I understand my plans shall be used aspublic records. to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save Licensed Professional 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buildina(aD-cupertino orq 11 NEW CONSTRUeTTOI`T n a „,T rTn*r 1-1 71 --� - nr iriv il�Iv r u u 1tt VISION / DEFERRED ORIGINAL PERMIT a PROJECT ADDRESS / I APN 3 , ®I 40 Mr O ANERNANM rl1 i . 0Op —E%SIL%% � -: J Ji�W�1v+�[tCCi� ST D S STAT > ZIP � ln F ( 1 Uf_ (I e{ - CONTACT NAME PHONE A-2 LAi t t r F MAR Lt 1 f_- �GO Zi r`e 1 d7 t f " STREET ADDRESS I CITY, ST.T LL nf�- O'ANER ❑. OWNER -BUILDER ❑:O'�NNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT �O'ENGLNEER L7 DEVELOPER 1:572ENANT CONTRACTOR NAME t-b'� 1 t � .. LICEATSENUI,4e1-R LICFASE TYPE BUS. LIC FAX COMPANY NAME i E-MAIL STREET ADDRESS CITY, STATE, ZIP PHONE ARCHrrFCT/ENGiLtEFR NAME I LICENSE NUMBER BUS. LIC 9 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE; ZLP PI-1011M DESCRIPTION OF WORK/-r� $ �✓ ! (Cell— C> im1 EXISTING USE PROPOSED USE 1 - CONSTR TYPE 4 STORIES - - f r -641A1 ti( USE TYPE ( OCC. SQ.FT. VALUATION (S) FXISTG AREA NWFLOORF AREA DEMO AREA .. TOTAL NET AREA BATHROOM - KTTC M'q OTHER REMODEL AREA REMODEL AREA. REMODEL AREA PORCH AREA DECK AREA TOTALDECI:/PORCHARE A GARAGEAREA: DETACH ❑ ATTACH n DR ET LII*G UNITS: IS A SECOND UNrr ❑ 1'ES SECOND STORY ❑1'ES BEING ADDED? ❑NO ADDITION? E]NO �Isjzg]j y -- . -" �.. � -, TOTAL�ALUATION: 'A PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OFIS PLANNINGAPPLR ❑NO PLANN,2\TGAPPROVAL LETTER .I THE BLDG AN ❑ YES EICHLERHOME? NO 9� 0 By my signature below, I certify to each of the f !lowing: I am t prope owner or orized on the property owner's behalf. I have read this 4a application and the information I have provide is correct. I h e read Description of �Trork an verify it is accurate. I agree to -comply with all applicable local ordinances and state laws rely�ou'nstruct'n. nze representatives'of Cupertino to enter the above -dent fled property for inspection purposes. Signature ofApplicant/Agen Date: / l SUPPLEMENTAL INFORMATION REQUIRE33 : or cs-h .-; — New SFD or Multifamily d,,N elIings: Apply for demolition permit for existing buildings}, Demolition permit is required prior to issuance ofbuilding 041;R:TWgQQTJhTER BU)I.,DLNGPLA[i?.REVSE43r-=`�- - _ permit for new building. �� E ss �,r�„ - L p s a 1'L1ZkGPI,ANREVIEV4W 'z-. Commercial Bldgs: Provide a completed Hazardous Materials Disclosures p x �� _ form if any Hazardous Materials are being used as part of this project. f>'uairc�WfV450 L . . Copy of Planning Approval Letter or Meeting with Planning prior to SEF'ERfDISTRIQ, submittal of Building Permit application. ' ?n�• � ..[`��: ., �"�� fl1ROlY'NTEiiHEAZTH ��-_s B1dg,4p,p 2011.doc revised 06/21111 9)t zLr'� 2P07s CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 10425 S DE ANZA BLVD DATE: 09/09/2015 • REVIEWED BY: MELISSA APN: 359 17 019 BP#:•f *VALUATION: $5,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: Commercial Building Civil/Religious activities PENTAMATION • in BQ zone? 0 Yes No PERMIT TYPE: 1 GENCOM WORK INSTALL TEMPORARY HALLOWEEN STORE IN E OCCUPANCY FOR -LIMITED TIME PERIOD SCOPE llech. Platt Che"".. Phli nri. Plan (Yzeck Elec. Platt Cheek I I tdeela. l'er<nit Fee: I'lu b f t r nir Fee: 1'lec--IPennitrii Fee: Cater Mech..htsp. 1 Ehlaet-Iluinb.hzs'1�_ Other Elec. hisp. :ifech. Insp. Fee: Phitnll. Insp. Fire: Ll€'a. Insp. Fee: NOTE: This estimate does not include fees due to other Departments! (Le. Planning, Public Works, Fire, Sanitary Sewer District, School Uzstrzct, etc.. "These fees are based on the prelimina information available and are onl an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee:Resolution 11-053 Eff'.' 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes 0 No $0.00 2 hours Plan Check, Hourly $286.00 1STPLNCx Suppl. PC Fee: iE) Reg. 0 OT 0.01hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes No $0.00 Suppl. Insp. Feer Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXC Admini,8jr4jtji,,e Work Without Permit? 0 Yes (!) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential t Building or Structure if€:ive:'11�t)Ctlrilc'Y1tt1iC3%1 �"'E�c',S.' Strong Motion Fee: IBSEISMICO $1.40 2.0 hrs Inspections $286.00 1STINSP Inspection, Hourly Bldg Stds Commission Fee: IBCBSC $1.00 -JSx� STQ�T,S}° $2.40 $572.00 T4T1E~JG $574.40 Revised: 07/02/2015