15040024CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10869 N WOLFE RD
CONTRACTOR: INTERSTATE
PERMIT NO: 15040024
CONSTRUCTION GROUP
OWNER'S NAME: CUPERTINO VILLAGE LP
437 29TH ST NE STE F
DATE ISSUED: 10/01/2015
OWNER'S PHONE: 4252090156
PUYALLUP, WA 98372
PHONE NO: (253) 435-0949
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
MOD SUPER FAST PIZZA- COMM T.I INTERIOR BUILD OUT
License Class Lie. #
TO INCLUDE M,E,P'S (CUPERTINO VILLAGE)
Contractor
I hereby affirm that I a 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: $192000
�. 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
APN Number: 31605052.10869
Occupancy Type:
rformance of the work for which this permit is issued.
2. I and will maintain Worker's Compensation Insurance, as provided for by
Lve
on3700 ofthe Labor Code, for the performance of the work for which thispeit
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
180 DAYS FROM LAST CALLED INSPECTION.
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
-_ i11JQ
upon the above mentioned property for inspection purposes. (We) agree to save
Issued by: Date: !0
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 Leguiations p e Cupertino Municipal Code, Section 9,18.
RE-ROOFS:
� .All
roofs shall be inspected prior to any roofing material being installed. If a roof is
Signature Date �� /�P
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
❑ OWNER-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:
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)
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
9. 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
Owner a or' gent:
Section 3700 of the Labor Code, for the performance of the work for which this
Date:
permit is issued.
3. I certify that in the performance of the work for which this permit is issued, I shall
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
CITY OF CUPERTINO
IOWA
IVU -Vc!rVTA4 A rrnlD — 11-FT111 1111VV— D-tVIQION
ADDRESS: 10869 n wolfs rd
DATE: 0410312015 REVIEWED BY: Mendez
APN:
BP#:
*VALUATION:
L$192,000
*PERMIT TYPE: Building Permit
PAN HEh&YPEa "
Tenant Improvement
PRIMARY Commercial Building
USE:
$2,521.09
IATIPLNCK
PENTAMATION 1A TI
PERMIT TYPE:
WORK
mod super fast pizz- comm Li interior build out to include. m,e,p's
SCOPE
$0.00
L
OCCUPANCY TYPE:
TYPE OF
CONSTR.
F,LR S.EAREA
()
PC FEES
PC FEE ID
BP FEES
BP FEE ID
A (Tenant Improvements)
J
11-8,111-BjV,V-B
2,575
$2,521.09
IATIPLNCK
$1,467.57
IATHNSP
$0.00
L
Suppl. Insp. Fee -(F) Reg. 0 OT
0.0
hrs
PME Unit Fee:
PNM Permit Fee:$0.00
$0.00
0
G
Select a Nin -Residential G
Building or Structure 0
T=
'
r.amimstralivellce:
NYeso
Work Without Permit? 0 No
TOTALS:
2,575--]
$2,521.09
$1,467.57
Select an Administrative Item
$0.00 19TAL V $4,050.42
Pee: lili C. Permit Fee.,
Other A "1"b l'Isa Other 1,170C.
Ey
AJI F— hi,,w. Fee.- Elec. insp. 1-.,e:
1� r— A... m ,thar 1)an"rtmontv 17 P- Planning. Public Works, Fire, Sanitary Sewer District, School
dd't
District, etc.). 77zeseftes are based on the prelimina information available and are only an estimate. Contact the Dept fiv an-into.
FEE ITEMS (Fee Resolution 11-053 Eff 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,521.09
Select a Misc Bldg/Structure
or Element of a Building
E= .4
Suppl. PC Fee: (j) Reg. 0 OT [:O:.LO. L hr's
PME Plan Check:
$0.00
$0.00
Permit Fee:
$1,467.57
$0.00
L
Suppl. Insp. Fee -(F) Reg. 0 OT
0.0
hrs
PME Unit Fee:
PNM Permit Fee:$0.00
$0.00
0
G
Select a Nin -Residential G
Building or Structure 0
T=
'
r.amimstralivellce:
NYeso
Work Without Permit? 0 No
$0.00
$0 $0.0000
Advanced Planning Fee:
TrOlvel Docamenladon Fees:
Strona Motion Fee: lBSEISMICO
$53.76
Select an Administrative Item
$0.00 19TAL V $4,050.42
Bldg Stds Commission Fe IBCBSC
$8.00
$4,050.42.
SU0-TA
Revised- 02/14/2015