14010121 CITY OF CUPEKTINO BUILDING PERMIT
BUILDING ADDRESS: 10983 N WOLFE RD. CONTRACTOR:ROBERTS MANAGING
PERMIT N0: 14010121
CONTRACTORSINC
OWNER'S NAME: CUPERTINO VILLAGE LP 5045 E MCKINLEY AVE DATE ISSUED: 10/06/2015
OWNER'S PHONE. FRESNO,CA 93727 PHONE NO:(559)252-6000
iJOB DESCRIPTION: RESIDENTIAL
LICENSED CONTRACTOR'S DECLARATION ❑ COMMERCIAL ❑
DEMOLISH TENANT SPACE WITH COVERED PORCH(812 SQ
FT)
License Class Lic.# 0-�=
Contractor I�1�1�'I - Date t 'UO"l
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:$0
1. 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 APN Number:31605050.10983 Occupancy Type:
F 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 is issued. . PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I certify that 1 have read this application and state that the above information is 180 DAYS FROM LAST C LED 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 en
upon the above mentioned property for inspection purposes. (We)agree to save I ��
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, Ad 'tionally,the applicant understands and will comply with RE-ROOFS:
all non-point so 'regul f n er the Cupertino Municipal Code,Section 9.18.
All roofs shall be inspected prior to any roofing material being installed.If a roof is
Signature Date (d `�; installed without first obtaining an inspection;i agree to remove all new materials for
inspection.
❑ OV( IER=B•> R Ii,ECLARATION Signature of Applicants Date:
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
i. 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
Healt &Safety Code,Sections 25505,25533,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 O r or da ,
Section 3700 of the Labor Code,for the performance of the work for which this - -., Date: (6 -
permit is issued. ,
3. I certify that in the performance of the work for which this permit is issued I shall O STRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the Worker's
.Compensation law of California. If,after making this certificate of exemption,I I hereb . ere is a construction lending agency for the performance of work's
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
0
EE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10 N WOLFE RD DATE: 01/21/2014 REVIEWED BY: MELISSA
APN: 31605052.10869 BP#: EVALUATION: $5,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition/Repair
PRIMARY Commercial Building PENTAMATION 1GENCOM
USE: g PERMIT TYPE:
WORK DEMOLISH 1,580 S.F. Of TENANT SPACE INCLUDING COVERED PORCH AREA & E DRIVE
SCOPE THRU'(768 S.F.)
WGr
so-11 R RP 01
WQ
ON
z
�. q -
Mech.I"tan(heck. Phwib. Plc i Check Dec.Plan Check.
.Meeh—Perwit Fee; Plumb.Permii Fee: Ftec.Permit Tee:
Other.t2eeh.l�zsf.
Other Plurrtlrfnsf�. 0iher Elec.Insp.
Lj
.ltr:cEIF
h.Insp flee: P7uta?b.hisi).Fee L;lec.fnip l^'c:e:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE I.TEMS(Fee Resolution 11-0531 ff 711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 2 hours Plan Check,Hourly
Suppl.PC Fee: (j) Reg. 0OT 0.0 hrs $0.00 $278.00 1STPLNCK
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl.Insp.FeesQ Reg. 0 OTQ.0 hrs $0.00
PME Unit Fee: $0.00 - -
PME Permit Fee: $0.00
C;0ns1P-ucilon K'Lv:.
F-1
Adininistr°ative.l7 eco:
Work Without Permit? ®Yes ONO $0.00
G)
Advanced Planning Fee: $0.00 Select a Non-Residential
Building or Structure
Travel Documentation T'cies: �
StroMotion 1BSEISAOCO $1.05 Select an Administrative Item
m
Bldg Stds Commission Fee:. 1BCBSC $1.00
u $280.05
$278.00
Revised: 01/15/2014