13040074 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10440 S DE ANZA BLVD CONTRACTOR:PROVISION PERMIT NO:13040074
DEVELOPMENT,INC.
OWNER'S NAME: MING WU 510 LAWRENCE EXPWY STE 105 DATE ISSUED:05/21/2013
OWNER'S PHONE: 5109281808 SUNNYVALE,CA 94085 PHONE NO:(408)245-0991
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALEI
Licens Class SUITE D4-DR.WU DENTAL OFFICE-COMM T.I 2,778 SQ
FT
Contractor � ti . Date
Ihe`e,.yaffirm that I am licensed under the provisions of C apter 9' REVISION#1-RELOCATE A MOP SINK&MODIFY ROOM
(co encing with Section 7000)of Division 3 of the Business&Professions WALLS-ISSD OTC 7/18/2013
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two 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. Sq.Ft Floor Area: Valuation:$250000
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 N Numbe � b940038.10440 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION ��
I certify that I have read this application and statedinanthat the ab . PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county orces laws relating WIT 80 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAP F OM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against_li4ilities,judgments,
costs,and expenses which may accrue againstt,saidCity ip-e6nsequence of the
granting of this permit. Additionally,the applicant erstands and will comply Issued by: Date:
with all non-point source reglati6iis pef the pertino Municipal Code,Section
9.18. °.".'._
/ RE-ROOFS:
Signature/ _ Date f 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. I will
I 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 Cupertino Municipals ,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533 aAd`25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: r Date: I ` '
permit is issued. f
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I tfereby 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
I
ADDRESS: 10440 S DE ANZA BLVD DATE: 04/29/2014 REVIEWED BY: SYLVIA/SUE
APN: BP#: 13040074 *VALUATION: Iso
'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION
USE: PERMIT TYPE: 1 GENCO
WORK R�E1-RELOCATE A MOP SINK& MODIFY ROOM WALLS
SCOPE DUPLICATE-NO FEE ESTIMATOR IN FILE FOR REVISION
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
B (Tenant Improvements) II-B,]11-BjV,V-B ��®v� �� p� /7571
TOTALS:
MECH,HOURLY 0 Yes No PLUMB,HOURLY 0 Yes G No ELEC,HOURLY 0 Yes Q No
NOTE.This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the preliminary information available and are only an estimate. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes No $0.00 hours Plan Check, Hourly
Suppl.PC Fee: 0 Reg. 0 OT F0.0 hrs $0.00 $278.00 ISTPLNCK
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee:(D Reg. 0 OT 0.0hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
T7
Work Without Permit? 0 Yes 0 No $0.00
Advanced Planning Fee. $0.00 Select a Non-Residential Q
- Building or Structure 0
Strom Motion Fee: $0.00 0 # Revisions
Bldg Stds Commission Fee: $0.00 $0.00 1REVSFDWL SFDWL
SUBTOTALS: $0.00 $278.00 TOTAL FEE:
at�ss� Revised: 04/01/2014
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10440 S DE ANZA BLVD CONTRACTOR:PROVISION PERMIT NO:13040074
DEVELOPMENT,INC.
OWNER'S NAME: MING WU 1288 KIFER RD STE 207 DATE ISSUED:05/21/2013
OWNER'S PHONE: 5109281808 SUNNYVALE,CA 94086 PHONE NO:(408)245-0991
Q. LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALE]
License Class ' Lic.#
T1 � SUITE D4-DR.WU DENTAL OFFICE-COMM T.I 2,630 SQ
/ FT
ContractorDate
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:
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. Sq.Ft Floor Area: Valuation:$250000
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:36940038.10440 Occupancy 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 WITHIN 80 AYS OF 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 180 DA F M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against ' bilities,judgments, /
costs,and expenses which may accrue against said- consequence of the �� [
granting of this permit. Additionally,the- " - t understands and will comply Issued by: Date:
with all non-point source regulationsie Cupertino Municipal Code,Section
9.18. - p ;
_ r RE-ROOFS:
Signatur Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without fust 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. I will
I 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 hazard6us
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which,erfit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air,QualityManiigement District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino MunicjpdtlCode,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.
Section 3700 of the Labor Code,for the performance of the work for which this / ,;: / r?
Owner or authorized agerft: �!' Date:_ I
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must, T 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10440 S DE ANZA BLVD DATE: 04/08/2013 REVIEWED BY: MENDEZ
APN: BP#: q CLQ VALUATION: 1$250,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY PENTAMATION 1 B TI
USE Commercial Building PERMIT TYPE: A
WORK. DR.WU DENTAL OFFICE-COMM T.I 2,630 SQ FT
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. (s.L
B (Tenant Improvements) II-B,111-B,IV,V-B 2,630 $2,170.40 1BTIPLNCK $2,206.16 1BTIINSP
TOTALS: 2,630 $2,170.40 $2,206.16
MECH,HOURLY 0 Yes E) No PLUMB,HOURLY ® Yes G No ELEC,HOURLY,' ® Yes G No
I Tech.Plan Check Numb. Plan Check Elec.Plan Check
Xlech.Pe wit Fee: Plumb.Permit Fee: Elec.Permit Fee:
Oihee IL9ech.Insp. Other Plumb Insp_ Other Elec.Insp.
lllech.Insp.Fee:, Plumb. Insp.Fee: Elee.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(i.a Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These&es are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS, ee Resolution 11-053 E . 7{f 11112) FEE QTY/FEE MISC ITEMS
Plan Check Fee`.' $2,170.40 Select a Misc Bldg/Structure
Suppl.PC Fee: E) Reg. .® OT 0.0 hrs $0.00
or Element of a Building.
PME Plan Check: $0.00
Permit Fee: $2,206.16
Suppl.Insp.Fee:Q Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Constr-ztction Tax:
A dmiaistrative Fee:
Work Without Permit? Yes (j) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential G
Building or Structure
Travel Docuinentation Fees:
Strom Motion Fee: IBSEISMICO $52.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $10.00
SUBTOTALS:T$4,439.06$4,439.06 $0.00 TOTAL FEE: $41439.06
Revised: 04/01/2013