15110102I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10869 N WOLFE RD I CONTRACTOR: ROBERTS MANAGING S INC I PERMIT NO: 15110102 I
I OWNER'S NAME: CUPERTINO VILLAGE LP 15045 E MCKINLEY AVE I DATE ISSUED: 12/03/2015
OWNER'S PHONE: 6507467503 1 FRESNO, CA 93727 1 PHONE NO: (559) 252-6000
Ud LICENSED CONTRACTOR'S DECLARATION
License Class P� • , Lie. #
Contractor Date E-{._ 5:1 7r
I hereby of i in ia,.t I am I'ensed under the provisions of Chapter 9
(commencing wectiod 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:
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
rformance 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.
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 ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to ent
upon the above mentioned property for inspection purposes. (We) agree save
indemnify and keep harmless the City of Cupertino against liabilitie dgme�
costs, and expense hich may accrue against said City in conse nce of the
granting of this e it. Additionally, th applicant understands and will co with
all non -point so rc6 r gulati seer the upertino Municipal Code, Section 9.18.
Signature ! Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 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
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
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
performance of the work for which this permit is issued.
2. 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.
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
Compensation laws of California. If, after making this certificate of 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 be deemed
revoked.
APPLICANT CERTIFICATION
1 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
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 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
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
RENOVATION AND REMEDIATION OF BUILDING OVERHANG AT
EAST CORNER OF BUILDING 3. ARCHITECT AND
STRUCTURAL ONLY.
Sq. Ft Floor Area: I Valuation: $0
APN Number: 31605052.10869 Occupancy Type:
PERMIT EXPI ORK IS NOT STARTED
WI 80 DAYS OF IT ISSUANCE OR
180 -'i ALLED INSPECTION.
I Date:
c� RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 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.
Additionally, should I use equipment or devices which emit hazardous 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 the
Health & Safety Code, Sections 5505, 25533, and 25534.
Own r o orized'ag -
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTlI440
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX.(408) 777-3333 - building(aDcupertino.org
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1 511oro.")
ORTt TTNAL PERMIT #
--
PROJECT ADDRESS
10869 N. Wolfe Road Cupertino, CA 95014
APN #
316-05-050
OWNER NAME
Cupertino Village LP I Kimco Real - Todd Dewell
PHONE
650-746-7503
E-MAIL
tdewell@kimcorealty.com
STREET ADDRESS
15 South ate Avenue, Suite 201
CITY, STATE, ZIP
Dal Cit , CA 94015
F650-756-3390
CONTACT NAME
Field Paoli Architects - Trish Beckman
PHONE
415-788-6606
E-MAIL pkb@fieldpaoli.com
STREET ADDRESS
150 California St 7th Floor
CITY, STATE, ZIP
San Francisco CA 941111
FAX
415-788-6�:A
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT qA ARCHrrECT ❑ ENGINEER ❑ DEVELOPER
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYP
L4t
BUS. LIC #
RoroCar ill
COMPANY NAME
RMC Constructors
E-MAIL
rcar ill rmc-constructors.com
FAX
559-252-9752
STREET ADDRESS
5045 E. McKinley Avenue
CITY, STATE, ZIP
Fresno CA 93727
PHONE
559-252-6000
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
Trish Beckman
COMPANY NAME
Field Paoli Architects
E-MAM
pkb0ifieltinggli.com
FAX
415-789-6650
STREET ADDRESS -
150 California Street 7th Floor
CITY, STATE, ZIP
San Francisco CA 94111
PHONE
415-788-6606
DESCRIPTION OF WORK
Renovation and remediation of building overhanat east corner of Building 3. Architectural and structural only.
No changes to existing plumbing, mechanical, electrical or firesprinkler systems. Work does not alter existing
building envelope energy performance.
EXISTING USE
PROPOSED USE
CONSTR. TYPE
# STOZES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
M
N/A -No Change
N/A
EXISTG NEW FLOOR DEMO TOTAL
AREA N/A AREA 0 SF AREA 0 SF NET AREA N/A
BATHROOM KITCHEN OTHER NIA
REMODEL AREA NIA REMODEL AREA N/A REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
N/A ❑ ATTACH
N/A N/A N/A
#DWELLING UNITS: ISA SECOND UNIT ❑ YES
BEING ADDED? ❑NO
SECOND STORY []YES
ADDITION? ❑NO
NIA
PRE -APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECE I?$Y
TOTAL VALUATION:
PLANNING ADPL # []NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
By my signature below, I certify to each of the following: I am the property owner or authorized gent to act on .property owner's behalf. I have read this
it is I agree to comply with all applicable local
application and the information I have provided i co a e read the Description of Work and verify accurate.
I representatives of Cupertino to enter the above -identified property for inspection purposes.
ordinances and state laws relating to building cos c orize
Date: 11.9.2015
Signature of Applicant/Agent:
SUPPLEMENTAL INFO A QUIRED PLAN une ROUTING SLIP
-_
J.
New SFD or Multifamily dwellings: Apply for demolition permit for p o�,ER T$E-CUUNTER D BUILDING PIAN REVIEW
_
existing building(s). Demolition permit is required prior to issuance of building
❑EXPRESS PLANNING PLAN REVIEW
permit for new building.
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ 'STANDARD II PUBLIC WORKS
_
form if any Hazardous Materials are being used as part of this project. = '
_ Copy of Planning Approval Letter or Meeting with Planning prior toARY SEWER DISTRICT:
submittal of Building Permit application. '`
1] ENVIIiON14IENTAL.HEALTH
BldgApp_2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR.- BUILDING DIVISION
ADDRESS: 10869 N Wolf Rd DATE: 11116/2015 REVIEWED BY: Phuong
121APN: ',316-05-050, —FBP#: *VALUATION: I$o
:*PERMIT TYPE: Building Permit PLAN CHECK TYPE: , Tenant Improvement
PENTAMATION
USE: 1GENCOM
PRIMARY:. Commercial Building —F PERMIT TYPE:
woRx - Renovation and remediation of building overhang at east corner of Building 3. Architect and structural
SCOPE: only.
A Yeeh. 11kil"I
klfech
Perriif Fee:
01kej Ae(: liup.
44
Phwib. jrtsi}. Fl;,e:
1.,.,iec, P'iar., Check
insp'. ET
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Divtrirt old -A Thovo foovarp h,7vod n" tho nrolimim7ru ;"Mr"-w6a" availahlo and aro only an Pvtim-ah,- Ctmtart the Dent for addn 'I info.
FEE ITEMS.(Fee .Resolution .11-053 Fff— 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes (D No
$0.00
= hours
$143.001
Plan Check, Hourly
ISTPLNCK
Suppl. P . C Fee: . (D Reg. 0 OT
0.0I
Iffs
$0.00
PME 'Plan' Check:
$0.00
Permit Fee: Hourly Only? 0 Yes (E) No
$0.00
Suppl. Insp. Fee. e; Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Aidininistradv,eFf ee:
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning_Fee:
$0.00
hours
$286.001
Inspections
ISTINSP Inspection, Hourly
0
D'dvel
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
,g
$0.00
$429.00
FEE EF il::
$429.00
Revised: 10/01/2015