13100137 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10215 S DE ANZA BLVD CONTRACTOR:MSS GENERAL PERMIT NO: 13100137
CONTRACTORS
OWNER'S NAME: SHTEIN PROPERTIES 30665 OLD HWY 395 DATE ISSUED:02/14f2014
OWNER'S PHONE: 3102757774 ESCONDIDO,CA 92026 PHONE NO:(760)751-5050
JW LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑
7 RADIO SHACK TENANT IMPROVEMENT(2240 SQ FT).
License Class Lic.# H rJ o,"]�`�bl�
Contractor m Date 01• i',"r r)
I hereby of irut 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 deelaratious:
I have and will maintain a eertifteate of consent to self-insure for Worker's
Compensation,as provided for by Seetion 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$50000
JJ 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:35910060.10215 Occupaney Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WI 80 D SOF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes, (We)agree to save AST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ,Y
granting of this permit. Additionally,the applicant understands and will c Is Aate; ` [
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
y`3 1 RE-ROOFS:
Signature("L! r + Date 1 1JAII roofs e insp ad prior to any roofing materi installed.If a roof is
stalled without rrs 'n n, o remove all new materials for
spection.
❑ OWNER-BUILDER DECLARATION
ure ofA Date:
I hereby affirm(lint I am exempt from the Contractor's License Law for
the following two reasons: ALL ROOVERINGS TO BE C "A"OR BETTER
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)
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,Seetions 25505,25533,and 25534. I will
I hereby affirul 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
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionsrlly,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 Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Seetion 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: ,b°' Dater F' L
permit is issued.
1 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 certiFeate of exemption,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 drat 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 aecrue against said City in consequence of the 1 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.
CITY OF CUPERTINO
FEE ESTIMATOR--BUILDING DIVISION
ADDRESS: 10215 S DE ANZA BLVD DATE: 10/21/201 3 REVIEWED BY: MELISSA
APN: 359 10 060 BP#: 43 *VALUATION: 1$50,000
*PERMIT TYPE: Building Permit PLAN CHECKTYP,E: Tenant Improvement
PRIMARY Commercial Building PENTAMATION 1B.TI
USE: PERMIT TYPE:
WORK RADIO SHACK-T.I. TO REPLACE SHELFS COUNTERS & CABINETS
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
B (Tenant Improvements) II-13,111-13,IV,V-13 2,240 $2,210.32 IBTIPLNCK $1,991.76 IBTIINSP
TOTALS: 2,24 $2,210.32 1 $1,991.76
MECH,HOURLY. 0 Yes 0) No , PLUMB,HOURLY a No 'ELEC,.ROURL;Y' Q Yes a No
Mech.Plan Check Numb,Plan Check Elec.Plan Check
;vfech.Permit Fee; Plumb.Petrnii Fee: Eley.•.Permit Fee:
Other Aiech.Insp. Other Plumb Insp. Orl;ee Elec.Insp.
,klech.hasp. I,ee: Phrmb, Insp. Fee: Flee.In.sP.Tcc:
NOTE.This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These ees are based on the prefinfina information available and are only an estimate Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053 Eft' 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $2,210.32 Select a Misc Bldg/Structure
Suppl.PC Fee: Q Reg. Q'OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $1,991.76
Suppl.Insp. FeelD Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee. $0.00
Construction Tov:
Administrative Fee:
Work Without Permit? Yes No $0.00 0
Advanced PlanninL Fee: $0,00 Select a Non-Residential
Travel Documentation Fees: Building or Structure
Strong Motion Fee: IBSEISMICO $10.50 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $2.00
SUBTOTALS: $4,214.58 $0.00 TOTALFEE; $4,214.58
Revised: 1 010112 01 3