14050100 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10765 N WOLFE RD CONTRACTOR:ROBERTS MANAGING PERMIT NO: 14050100
CONTRACTORS INC
OWNER'S NAME: .CUPERTINO VILLAGE LP 5045 E MCKINLEY AVE DATE ISSUED: 10/06/2015
OWNER'S PHONE: 6507467503 FRESNO,CA 93727 PHONE NO:(559)252-6000
LICENSED CONTRACTOR'S DECLARATION JOB.DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
2� DEMO(E)DRIVE THRU AND CANOPY&PARTIAL
License Classy q _ Lia.#_ �'JJ SURROUNDING SITE(768 S.F.)
Contractors"�(.r Date
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
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 APN Number:31645017.10765 Occupancy Type:
4 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. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS 4F4T4M ISSUANCE OR
I certify that I have read this application and state that the above information isYp9 + j�j LA LTSD INSPECTION.
correct.I agree to comply with all city and county ordinances and state laws relaf
to building construction,and hereby authorize representatives of this city to en ��
upon the above mentioned property for inspection purposes. (We)agree to sa Date:
indemnify and keep harmless the City of Cupertino against liabilities,judg
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. 4Aditionally,the applicant understands and will comply with RE-ROOFS:
all non-point s e re tions per the Cupertino Municipal Code,Section 9.18.
/ All roofs shall be inspected prior to any roofing material being installed.If a roof is
Signature L Date /0-0(, 'f installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ WNER-B ER DECLARATION Signature of Applicant: 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:
�. I,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. 1 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
Health&Safcq 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 Ow r au 1h d cnt: .o
Section 3700 of the Labor Code,for the performance of the work for which this Date: Co0& 0
permit is issued. "7
a. I certify that in the performance of the work for which this permit is issued,I shall )LTRUCTION 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 ofthis permit.Additionally,the applicant understands and will comply with
all non-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333-buildina(ocupertino.ong
PROJECT ADDRESS
10765 N.Wolfe Road Cu ertino CA 95014 Buildin 6 APN# 316-45-017. d
OWNER NAME PHONE E-MAIL
Cupertino Village LP-/Kimco Real! -Todd Dewell 650-746-7503 tdewell@kimcorealty.com
STREET ADDRESS CITY, STATE,ZIP FAX
15 Southgate Avenue, Suite 201 Daly City, CA 94015 1 650-756-3390
CONTACT NAME PHONE E-MAIL
Field Paoli Architects-Trish Beckman 415-788-6606 pkb@fieldpaoli.com
STREET ADDRESS CITY,STATE, ZIP FAX
150 California St 7th Floor San Francisco CA 9411'1 415-788-6650
❑OWNER D OWNER-BUILDER ❑ OWNER AGENT ❑CONTRACTOR ❑CONTRACTOR AGENT XARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC
Patrick Trac 69:1N -
COMPANY NAME E-MAIL FAX
Midstate Construction atrickt midstateconstruction.com 707-762-0700
STREET ADDRESS CITY,STATE,ZIP PHONE
1180 Holm Road Petaluma CA 94954 707-762-3200
DESCRIPTION OF wORIf _
Demolition of drive-through ATMs and canopy. Limited demolition of surrounding site.
RESIDENTIAL #DWELLING - OFFICE USEONLY.
FLOOR AREA NIA UNITS N/A
. .USE .. "G, TYPP. SO.Fr.. VALUATION
COMMERCIAL
FLOOR AREA 768 SF
TYPE OF CONSTRUCTION #STORIES
1
AQMD JOB NUMBER F.D' TOTAL VALUATION:
By my signature below,T certify tomb of the following: I am the property owner or authorizedac rie property o s behalf. I have read this
application and the information T have provided is correct. I have read the Description of Work and verify is rr�i . agree to comply with all applicable local
ordinances and state laws relating to buil ' ction. I a orize rep rese pertlno to enter the above-identified pr9perty for inspection purposes.
Signature of Applicant/Agent: Dater
SUPPLEMENTAL INFORMATION REQUIRED PRI ISSUANCE OF DEMOLITI04PERM[If OFFICE USE ONLY
Provide Job Number from Bay Area Air Quality Management District lvww.baagmd.ora @ 415-749-4762. PLAN CHECK TYPE
Provide three copies(Residential)or six copies(Commerical)of a site plan showing protection for any trees 10" 0 EXPRESS
in diameter or more at 3'above grade. ❑ STANDARD
_Provide letter from PG&E(408-725-3325)stating all gas and electric has been disconnected. 0 LARGE
Provide a letter of inspection,tests,and abatement of any Hazardous Materials.Letter to be initiated by person(s) El MAJOR
certified in asbestos,mercury and/or hazardous material examination.
Planning Dept clearance to verify building is not considered an historical landmark.Allow 10 business days.
Provide letter of clearance of all vermin from a licensed pest control contractor-
-Applicant shall call the Public Works Department at 408-777-3104 and schedule a"habitable dwelling"inspection.
Provide signed Debris Bin and Recyclable Materials form.
DemoApp_2013.doc revised 02/13/13
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10765 N WOLFE RD DATE: 05/15/2014 REVIEWED BY: MELISSA
12[APN- 31645017.10765 BP#: 'VALUATION: 1$5,000
PERMIT TYPE: Demolition Permit
PRIMARY Commercial Buildin PENTAMATION
USE: 9 PERMIT TYPE: 1 COMMLDE
WORK DEMO E DRIVE THRU AND CANOPY & PARTIAL SURROUNDING SITE 768 S.F.
SCOPE
FEE ID FLR AREA
s.f.
1DEMOCOM 768
.f.r, f'.
23iEJr,f
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the prelimina information available and are only an estimate. Contact the Dept/or addn'l into.
FEE ITEMS (Fee Resolution 11-053 7./f 1/13) FEE QTY/FEE MISE ITEMS
A
Permit Fee: $557.00
Suppl.Insp. Fee:Q Reg. Q OT Q,Q hrs $0,00
I `f
W-!,
,
iii!`; j:: irg r...i.
Strong Motion Fee 1BSEZSAECO $1.05 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $559.05 $0.00 TOTAL FEE: $559.05
Revised: 04/01/2014