14050052CITY OF CUP EIE TINO BUILDING PERMIT
BUILDING ADDRESS: 10495 N DE ANZA BLVD
CONTRACTOR: XL CONSTRUCTION
PERMIT NO: 14050052
OWNER'S NAME: HATCO ASSOCIATES LLC
851 BUCKEYE CT
DATE ISSUED: 05/08/2014
OWN'ER'S PHONE: 4153619112
MILPITAS, CA 95035
PHONE NO: (408) 240-6000
❑ LICENSED CONTRACTOR'S DECLARATIONJOB
DESCRIPTION: RESIDENTIAL COMMERCIAL
APPLE- OOMflM .T1 TO IST FLOOR CONVERT SPACE TO
License Class Lic.4 19434-121BREAKROOMH
��//
Contractor 1((- &NA�,-YeW- f 41) Date'
hereby affirm that I am licensed under the provisions of hapter 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:
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
Sq. Ft Floor Area:
Valuation: $75000
'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
APN Number: 32633110.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES jEF WORK IS NOT STARTED
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
WITIH Nfl ® DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We) agree to save
180 QDAY R ]LASS' CALLED1 O�.
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 rmit. Additionally, the applicant understands and will comply
Issued by: Date: O
with all non-po source regulations per the Cupertino Municipal Code, Section
9.18.
�j
RE -ROOFS:
SignatureloaDate a
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.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertin Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sectio 255 5, 2 33, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
/
Owner or authorized agent: Date: d
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 ofexemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records,
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 - building akugertino.oro
[INEW CONSTRUCTION El ADDITION
ALTERATION / TI
❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS _
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CONTACT NAME
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❑ OWNER ❑ OWNTER-BUILDER ❑ OWNER AGENT IXCONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
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CONTRACTOP, NAME I (O
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LICENSE TYPE
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ARCHITECT/ENGINBER NAME
LICENSE NUMBER
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COMPANY NAME _
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E-MAIL
FAX
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STREET ADDRESS
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CITY, STATE, ZIP ` rT
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PHONE
DESCRIPTION OF WORK
-t
EXISTING USE
PROPOSED USE CONSTR.
TYPE
k STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
pyo
J�
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BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑ YES
BEING ADDED? ❑NO
ADDITION? ❑NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED B 'ti'
TO L VALUATION:
PLANNINGAPPL9 [:]NO PLANNING APPROVAL LETTER
EICHLERHOME? ❑NO
f the following: I am the property owner or authorized a - Int to ac n the roperty owner's behalf. I have fead this
By my signature below, I certifJ�htaevaec
application and the informationvided is corre ave read the Description of Work and verify accurate. I agree to comply with all applicable local
ordinances and state laws relatilly on truct' I authorize representatives of Cupertino to ent the above -identified property for inspection purposes.
Date: Z.
Signature of Applicant/Agent:
SUPPLEMENTA13 INFORMATION. REQUIRED
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CHECFCTYPE_ � i
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New SFD or Multifamily dwellings: Apply for demolition pen -nit for
existing building(s). Demolition permit is required prior to issuance of building
w k
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permit for new building.
EaPR SS M,
'®,�P"IgNC+mGp AN REVIEW
Commercial Bldgs: Provide completed Hazardous Materials Disclosure
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form if any Hazardous Materials are being used as part of this project.pi
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LARGE
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of Planning Approval Letter or Meeting With Planning prior to
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❑sArrrAxY
_Copy
submittal of Building Permit application. '�MAaoR�
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I B1d;App_2011.doc revised 06/21111
CITY OF CUPERTINO
FEE ]ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
ADDRESS: 10495 N De Anza Blvd
DATE: 05/08/2014
REVIEWED BY: Mendez
PC FEE IID
APN:
BP#: I � �j _ --
*VALUATION: 1$75,000
xPERMI[T TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE:
IBTIPLNCK
PENTAMATION 1B TI
PERMIT TYPE: ZI
WORKA
le- Comm .ti to 1st floor converts ace to breakroom
SCOPE
Suppl. Insp. Fee:Q Reg. COT
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC PEES
PC FEE IID
BP FEES
BP PEE IID
B (Tenant Improvements)
II-8,111-B,IV,V-B
350
$2,041.11
IBTIPLNCK
$637.37
IBTIINSP
i l-=. ,r'4,. l' c.
$637.37
Suppl. Insp. Fee:Q Reg. COT
0 0 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00 11
Construction Tax:
Ad1,,7hdsrrerrive Fac:
E)
Work Without Permit? 0 Yes (D No
$0.00
Advanced Planning Fee:
$0.00
TOTALS:
350
$2,041.11
Strom Motion Fee: IBSEISMICO
$637.37
Select an Administrative Item
li'1llECH, HOURLY 0 Yes (D No
]P1L><JN'1[]B, HOURLY Q Yes (E) No
IEILIEC, HOURLY Q Yes Q No
i cch Plan t 7i,-ck
Pli IIIh. t'tu,i C hcr(
$2,041.11
4lrcar- P"rnti1 Fck':
Suppl. PC Fee: (D Reg. C OT
0.0
olhe1" .V -ch. it?.shLi
Chher l'hia+b ir-'o;,j
-d
P:L
Oih, ,
it-kuh. lnsp_ FL":
phlmh Inv/). l'�r':
i l-=. ,r'4,. l' c.
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.
FEE ITEMS (Fee Resolution 11-053 Eft' 7/1/131
FEE
QTY/1FIEIE
MISC ITEMS
Plan Check Fee:
$2,041.11
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (D Reg. C OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$637.37
Suppl. Insp. Fee:Q Reg. COT
0 0 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00 11
Construction Tax:
Ad1,,7hdsrrerrive Fac:
E)
Work Without Permit? 0 Yes (D No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential G
L— I Building or Structure 0
T-sive+l Doc itm ntulion FUCS:
Strom Motion Fee: IBSEISMICO
$15.75
Select an Administrative Item
Bldy Stds Commission Fee: IBCBSC
$3.00
SUBTOTALS:
$2,697.23
L $0.00
TOTAL FEE:
$2,697.23
Revised: 04/01/2014
,fipple Subcontractor License
CONSTRUCTION
Subcontractor
Cupertino Business License #
Advanced Glass
25685
Bayside Interiors
4 25898
25
California Blind Co.
-75 6 92 ff5
25647
Canterbury Contractors
Redwod City Electric
21108
United Mechanical
27361
Welker Bros.
25264
XL Construction
21836