13050025 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10883 S BLANEY AVE CONTRACTOR:PROVISION PERMIT NO:13050025
DEVELOPMENT,INC.
OWNER'S NAME: PACIFIC RIM PARK LLC 510 LAWRENCE EXPWY STE 105 DATE ISSUED:06/27/2013
OWNER'S PHONE: 4082600257 SUNNYVALE,CA 94085 PHONE NO:(408)245-0991
LICENSED CONTRA 'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALEI
License Class P2 ROLCO AFTERSCHOOL-SUITE A,COMM.T.I 3,200 SQ FT,
CHANGE OCCUPANCY FROM(M)TO(E)
Contractor Date 6 2 ?�?(
I h y affirm that I am licensed under the provisions of C apter 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:$135000
1 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:36934052.10883 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 180 DAX3L7Q ERMIT 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 DAY CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City i equence of the /3
granting of this permit. Additionally,the appli rstands and will comply a e:
with all non-point source regulations pertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date v,t 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
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,Sections 25505,25533,and 25534. 1 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 Ma ent District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Munici e,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533, 534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:,64 7/77-'
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[- 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
211AUFEE ESTIMATOR-BUILDING DIVISION
P
DDRESS: 10883 S BLANEY AVE DATE: 05/03/2013 REVIEWED BY: MENDEZ
N: BP#: � S "VALUATION: $135,000
'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1 E TI
WORK �ROLCO AFTERSCHOOL- COMM. T.I 3,200 SQ FT CHANGE OCCUPANCY FROM M TO E
SCOPE
OCCUPANCY TYPE: TYPE . s.f.FLR AREA
CONSTR. PC FEES PC FEE ID BP FEES BP FEE ID
E (Tenant Improvements) II-B,111-B,IV,V-B 3,200 $3,918.48 IETIPLNCK $4,279.64 1ETIINSP
TOTALS: 3,200 $3,918.48 1 $4,279.64
MECH,HOURLY 0 Yes (F) No PLUMB,HOURLY 0 Yes Q No ELEC,HOURLY 0 Yes Q No
Elec.Plara Check
Fcc. Elec. Permi7 F"e.
Otit�r:12eclz.hrsp. Other Plumb Insp. Li Other Etec.Insp. LT__L_
illec' Insp.I,ze: Fhmrh. 111.y. Fea Elcc.Irtp.1,oe:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These ees are based on the prelimina information available and are only an estimate Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $3,918.48 Select a Misc Bldg/Structure
Suppl.PC Fee: (E) Reg. 0 OT 0.0 1 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $4,279.64
Suppl. Insp. Fee:Q Reg. 0 OT0 0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
7-<��-.
:1.driministrati-Ve Fee:'' 0
Work Without Permit? 0 Yes 0 No $0.00 0
Advanced Planning Fee. $0.00 Select a Non-Residential
Travel Building or Structure 0
i
Strong Motion Fee: IBSEISMICO $28.35 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $6.00
SUBTOTALS: $8,232.47 $0.00 TOTAL FEE: 1 $8,232.47
Revised: 04/29/2013