12100003C11TY OF C11.. PEl18')<'1 NG BUff LD>ING P E1M11T
BUILDING ADDRESS: 10675 S DE ANZA BLVD CONTRACTOR: PROVISION PERMIT NO: 12100003
DEVELOPMENT, INC.
OWNER'S NAME: SEAGRAVES MARGARET TRUSTEE & E 1288 KIFER RD STE 207 DATE ISSUED: 10/30/2012
OWNER'S PHONE: 4088582818 SUNNYVALE, CA 94086 PHONE NO: (408) 245.0991
❑ LICENSED CONTRACTOR'S DECLARATION
License Class� Lic. # 12J b � 9'
Contractor PDAI Date 10/50/'2—
I
O d 'ZI hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business &c 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 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.
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 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 ex=Date
rue against said City in quence of the
granting of thly, the appli ands and will comply
with all non -ns e C mo Municipal Code, Section
9.18.
SignatureDate {F'21
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 sale (Sec.7044,
Business & Professions Code)
1, 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:
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.
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.
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, l must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION e_ --
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 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
BUJILDtNG PERMIT I[N]FO: BLDG r ELECT r PLUMB r
IMIECH r- RESIDENTIAL r- COMMERCIAL r—
JOB DESCRIPTION: Tl -FOOT MASSAGE STORE46-TO ADD PARTITION WALLS
TO
HAVE 3 MASSAGE ROOMS AND 1 MASSAGE AREA(885
SQFT).PROVIDE A WATER HEATER, MOP SINK AND HAND
Sq. Ft Floor Area: 1I Valuation: $15000
APN Number: 35923033.00 11 Occupancy Type:
PERMffT EXNRES RF WORK RS NOT STARTED
W> THffN Il 8® DAYS OF P E1L8MffT IISSNA C E ®118
180 DAYS IFIlB®"I�1�I�LAST CALLED ffNSPIECTRON.
Issued by: � ��/ ' Z � Dater®'2:1�119 -Z
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 c& Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health c&
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 Cupert' cipal Code, Chapter 9.12 and the
Health &c Safety Code, Secti , 533, and 25534.
Owner or a l�ize.�
Date: a
�
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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
CONSTRUCTION PERMIT APPLIICAT�®N
COMMUNITY DEVELOPMENT DEPARTMENT 0 BUILDING DIVISION
10300 TORRE AVENUE 0 CUPERTINO, CA 95014-3255
(408) 777-3228 0 FAX (408) 777-3333 0 building(ZDcupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION 54ALTERAI ION / Tl ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS 1001- �, De /I__Ze, Q _ _ ,I _ vlyd , FP I,FNN
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OWNERNAME G Gly
PHONE /V�^�� �i2$1$
E-MAIL /� /
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STREET ADDRESS ( o675- S 'Pe AD ze. $ Hilol
CITY, STATE, ZIP
(�7E-MAIL(/
FAX
CONTACT NAME VDI �j.� / /I_rAC� �{"
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STREET ADDRESS �Op'�►'�
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FAX (40g) 24 6TI
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT P ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSETYPE
BUS. LIC k
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, LIP
PHONE
ARCHITECT/ENGINEER NAME J01M Jqa
`,J r I
LICENSE NUMRrR n� I �Q
BUS. LICK
COMPANY NAME "� j� /� /
1•�
E-MAIL �'O l e lI0, 6 'j p, SJ . Ca—,
1Y1 l�l� L-I/I�f�OfJ��Wo� �
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FAX (i ) 41- _0711 / l
STREETAllDRESS '%'�iJn�(7
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Crl'Y,STATE,Z�IPry1(/�I
PITON\L'''{/-(JA^JQ�Ll,I S_ 0� c b
l�(lU 6'4C
DESCRIPTION OF WORK (
TD aid h vv- 3 /"✓1 aYt-'�tter WL!5 O.n j I 0 &$4oWy>0A .
Prvvi dz a,, bvatTr hem , tnzp 5irvk a Iiof hskj sink �GI
EXISTINGUSE 1 �_�
chert
pUSE
PROPOSED
� CONSTR.TYPE
T ate" I � mia
V ^ 8
kSTORIES
I
usE
TYPE=
Occ.
SQ.FT.
VALUATION ($)
FXISTG
AREA
NEW FLOOR .�
AREA IQ 7S
DEMO
AREA
TOTAL
NET AREA
BATHROOM
KITCHEN
OTHER
REMODELAREA /
REMODEL AREA /
REMODEL AREA
PORCH AREA
DECK AREA
ARE
GARAGE AREA: DETACH
[TOTALDECK/PORCH
❑ ATI'ACH
4 DWELLING UNITS:
ISA SECOND UNIT ❑YES
SECOND STORY DYES
BEING ADDED? []NO
ADDITION? ❑ NO
PRF. -APPLICATION [-I YES IF YES, PROVIDE COPY OF
ISTHE BLDG AN ❑YES
RECEIVEDBY:
TOTAL VALUATION:
PLANNING ADPL N ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
1 7vo O
By my signature below, I certify to each of the following: 1 am the property owner or authorized agent to act on the property ownerils behalr. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and stale laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Appl icanl/Agent: a r&(,C YJA Date: Act, 15't 2,012-
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
_New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
EXPRESS
❑ PLANNING PLAN RFVLEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ Putu,wwoRks
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARYSEWER DISTRICT
submittal of Building Permit application.
❑ EN'VIRONMENTAL14FAL'1'H
81dgApp_2011.doc revised 06121/11
,rI T'n'R7 r'h-" ir4Tr TTM1MTM 1n1TTT\T?T
OCCUPANCY TYPE:
�L..11 1L ll N.Y1r �L. lL Y 11'�llU 1L lll V �Ly
FEE ESTIMATOR - BUILDING G IDIVIKON
F1LR AREA
s.L
ADDRESS: 10675 S. De Anza Blvd. DATE: 10/01/2012 REVIIEWED BY: gs
PC FEE IID
AVN:
BPO: ! ��(/L��J
*VALUATION: 1$15,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY
Commercial Building
$1,979.40
PENTAMATIION
113 Ti
USE:
1BTIINSP
PERMIT TYPE:
$928.42
Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs
WORK
SCOPE
$0.00
OCCUPANCY TYPE:
TYPE OF
CONSTR.
F1LR AREA
s.L
PC FEES
PC FEE IID
BP FEES
BP FEE IID
B (Tenant Improvements)
II-B,111-B,IV,V-B
885
$1,979.40
IBTIPLNCK
$928.42
1BTIINSP
Permit Fee:
$928.42
Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Conslruction Tar:
Adininis trative .Fee:
0
Work Without Permit? Yes E) No
$0.00
Advanced Plannin& Fee:
$0.00
TOTALS:
885
$1,979.40
Strong Motion Fee: 1BSEISMICo
$928.42
Select an Administrative Item
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 nreliminary information available and are only an estimate Contact the Dent for addn'l info.
EEE ITEMS (Fee Resolution 11-053 Ef 7/1/11)
EEE
QTYIFEE
MISC RTEMS
Plan Check Fee:
$1,979.40
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (F) Reg. 0 OT0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$928.42
Suppl. Insp. Fee:Q Reg. ® OT 0,0 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Conslruction Tar:
Adininis trative .Fee:
0
Work Without Permit? Yes E) No
$0.00
Advanced Plannin& Fee:
$0.00
Select a Non -Residential G
Building or Structure �a
I
711uvei Documentation Fees:
Strong Motion Fee: 1BSEISMICo
$3.15
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$2,911.97
$0.00
TOTAL FEE: $2,911.97
07/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-.3255
C lJ t' FtT 1 N O Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR CTOR / SUBCONTRACTOR LIST
0
BUILDING*Our municipal code requires all businesses working in the city to have,aCity�of Cupertino business license.
NO OR OCCVPANCY IN i' SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINEDA CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontracts
Signature Date
Please check applicable subcontractors and complete the following information:
✓
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
GENERAL #A •
BUSINESS LICENSE
ADDRESS:
CIT-Y/APCODE-
0
BUILDING*Our municipal code requires all businesses working in the city to have,aCity�of Cupertino business license.
NO OR OCCVPANCY IN i' SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINEDA CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontracts
Signature Date
Please check applicable subcontractors and complete the following information:
✓
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
'
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature ate