12050146 CITY:OF,`CUPERTINO:•BLTILDING',FERMIT
BUILDING ADD_RESSa 10425 S DE ANZA,BL'UD CONTRACTOR:MCiFiC:GENERAL. PERMIT NO`:11650146
CONSTRUCTION:
OWNER?S NAME:-CAD REAL.ESTfiTE_L'LC: ]150 CADILLAC CT' . DATE. ISS.UEDi-12/4.2/2012
PWAWS•PHONE 5104878899° MILPI-TAS,CA 95035. PHONE NO:,(408)°•935'9233
LICENSED CONTRACTOR:.S-DECLARATION JOWDESCRIPTION: ,RESIDENTIAL L1 COMMERCIAL
LicenseiClass Laic.tt•'. 4Z TI'(RANCH 99)OF'EXISTING;29,000 SQAURE FEET OF
.SUPERMARKET SPA
_ CE;IN.CLUDING,1M.E.P.UPGRADES
Contiacto%-? ,&ZAQ6 Date:' u
1 hereby affirm that I am licensed under the provisions;of Chapter 9' -'� REV_ISI' # ADD'M_ETA_ L GATE'@ LOADING DOCK
(commencing with Section 7000),of Division 3'of the Business&Profe's" IO G1P5/2013,
C_o&,and that mi license is;in.' foree and effect_.
I hereby'affirm'under,penalty of perjury one of€the follo%400 l'haveand-will.mamtam a certificateiof'consentto selPinsuCompensation;*as provided for by Section3700 of,the:L"abo
performance ofthe.,work forwhicli"this permit is.issue
d: Sq.:Ft,Floor Area':. aluation:`.'$I500000
l,have,and'will maintain Worker's'Compensation'lnsurance,as'prov'ided-for.by
•Section 3700 ofthe Labor,Code for the perforin`ance%of the work,' r,which,this
APN.Numbm,35917019'-_1042'3 Occupancy Type:
- AP,P-LICANT'CERTIFICATION;
I certify that:Phave read this application and.st'afe thaf.the.above information.-is PERMIT EXPIRES,IF WORK.IS NOT STARTED.
correct..;I agreeao comply with all;city,and county ordinances andstate laws relating
to building construction,and'hereby_authorize`rep7esentatives of.thislc_rty fop enter WITIII, S_O=DAYSi OF'PERMIT ISSUANCE"OR,
'upon lheiaboye mentioned property fo7;inspection purpose's (We),agree to save ISO I) OM LAST'CALLED INSPECTION-.
indemnify and keep harmless the City of Cupertino agamsf liabilit1.ies judgments;. -
costs and expenses'which may accrue against said City in consequence of the Issued 6 Dater
granting of this- tfriit..Additionally,the applicant undersfands aridwillcomply Y'
with,all'iion-point source regulations;per the.Cupertino-lvlunicipal Code,Section _
P
9.18. - _
RE-ROOFS.
Signature Date; �`�~.j nstalled whthout frspecte npn ort inspection;g g g •of is
t
roofin material'bem installed.Tf a ro
g p ction;I a ree-to remove all;new,materials for
inspection.
13 ',OWNER-BUILDER.DECLARATION'
S ignature�of Appl icant Date:
I hereby°affrm that I=am,exenipt>from the Contr,actor.'-s,LieenselLaw for one of -
I as owner -, , r_, e or ` ALL ROOF,COVERINGS'TUBE'CLASS-"A"OR BETTER:
the following two reasons:
p;_p rty,' `iny employees:with wagesas their sole compensation,
will do.the`work,'and,the,structure is not;intended or offered for sale;:(Sec.7044„
ofessiohs Cod
Le
B as owri eofrthe property,am,e -
_ ' ) xclusively contracting with licensed'contractors to HAZARDOUS�MATERIAL'S DISCLOSURE
construdt j ic�'project(Sec 7044,'Business,&Prdfessions;CodC! I.have;read:the hazardo.'us materials.reggirement§•unile�Chapter6:95 of the
CalifOrnlaMeaftliA Safety°Code,Sectrons'25505,25533;;and•25534:Twill
I`.hereby affirin.gpder penalty'of.perjuryooe ofahe followmg;three maintain compliance withdthe CupertiuoMitnicipal,Code,Chapter,9;12 and the
declarations: Health,-&Safety Cbde,�Section°25532(a)should I store�or handle hazardous ..
tihave;and�will maintain a Certificatetof Consent-to,selfinsure•foroWOrker's material:.Ad'di6onally,s`houl'_` q •p f;azardous:
., u d I•use;e m merit or devices which�emit
Compensation-,,s. invrdedforby Section 3700 ofthe,0bor'Code;forthe. air,contaminantsaas defined-by"the'Bay_Area.ArrQuality ManagementfDistrict[
perf6rmance of the-wo_rkifor'%vhich this perriiit;is',issued. will maintain compliance with the Cupertino Municipal Code,Chapter9.12and
0
the Health&ISafe Code,Seetions.25505;r25533,and,25534.
� Worker s.Compensation insurance,as provided,forby - ty °.. '
I"have'and will maintain _
Section 3,700 of the.Labor Code for the pe"r'formance of the workifor which thi"s �-
Owner or authorized agent: Date:-
Odini6s issued. .. "
hcert ,
ify+that in4he performance,oftlie work for which this permitis-issued„Lsfiall
not employ any person m any mariMso,as to.become`subject to the?Worker's
'Compensation.aws�of 'alifomia. lf,'after making this certificate ofexeriiption,
CONSTRUCTION'S LENDING.AGENCY.
become:subject,fo the Worker.'s Coi ipen"sation piovisions of'the Labor Code,1 must, l hereby°affirm ihat1here is,awconstruction,lending agency`forthe;performanceiof
forthwith eomply-with,such pfovisions;' r this permit sh'-all`be deemed_ revoked. 'work's for'which this permit is issued,,(Sec:3097,Civ',C) .
Lender..'s:Name:
APPLICANT'.CERTIFICaTION Lender's Address
certify'that'l have'read"tliis:appl"-"n°and state that.the above informatiow.is
correct-J agree to.comply with all city and couiityordinances and,state laws relating4
io buildingsconstruction,:aind.hareby^authorize representatives ofthis city to enter
upon thexabovetimentroned,property'for inspection purposes (We)agree to-save
indemnify°and keep harmless the CnyNof Cupertino against'liabdities,judgments;
ARCHITECT'S DECLARATION
costs,ian&expenses'wliich mayaccrue agaiiist said City iwconsequencerof the '' Tunders"tand my�plans shall b6used as�piiblic records.
granting of this,,permit Additionally;the applicarit:unders'tands andkwill comply
wrth.all°non pont:source%regiilations per the'Cupertino Municipal Code,Section Licensed;:Professional
9.1&
Signature Date.
CITY OF CUPE•RTINO BUILDING PERMIT
BUILDING ADDRESS10425 S E TZ'A I3L�IL7 CONTRACTOR.iP GIFT IE `PERMIT NO: 205 i0 46•
- ,. C®NSTRUGTCON
OWNER'S'NAME•. C iI REAL S fEL i10 GAI7IL A DATE•ISSUED �2/12/20I2
OWNER'S PHONE. Si` 87$$99 I�LPiTAS A 95035 PHONE NO:(4 8 j9__3_3'r33'.
UtENSED'CONTRACTOR'S DECLARATION, JOB DESCRIPTION:'RESIDENTIAL COMMERCIALO
Licei s6ClassLic.# &37 4 ZZ TI tRANCH:s9)OI XTSTYNG 29;D00 sQAURE EET®F .
. - StTPERM�ARKETSP�AC�E•�NCt�'D�3!1'�h�EP G «�g ES
Contractor
C o,ision
Izhereby a �rm;that I am licensed under the;provislons,of"Chapter 9 1 a� SPUN#1=4REsISE PRE�YIUITSLY APP
(cornmencmg with Section 7000)of;Divisiow3 of the Business&Professions LINE-
Code,and that;my,license is'in.fulliforceaand effect.
1 hereby taffrm'underpenali-yof perjury-one'of the-following two,declarations:
l have;and'will maintain acertificate of consent to self'insure fof-Worker',s
:Comp en-s"ation as'proyided for by SectiW,3.700 dUhe.Labor,Code;,forthe
performance.'of'the.;work for"which this permit'is issued: Sq.F,t Floor"Area: Valuation.�,SOQ30
Chave and will4ffAintain Worker's Compep`sationInsurance;;as provided for`6y
+Section 3700 oftlieLabor Code,forthe"performance;of the work;for whi&this
APNNumber:9 0.19.!'0425' Occupancy Type:.
permitis.§sued.
APPLICANT CERTIFICATION'
I,certify:thatJ have read.this,application and state thaftfie alio've information is PERMIT.EXPIRES.IF"WORK ISNOT STARTED
correct>I agree to;cornplywith all city,and county ordinanccs'and state laws relating WITHIN 180'DAYS:OF PERMIT ISSUANCEUR
to building-constructiop„and hereby,atithoiize representaiiyes of this city to enter
upon iii'.above mentioned'property'for>tnspeciion purposes ()Ye)'4gre6 o save 180 DAYS.FROM.,LAS.T CALLED INSPECTION.
indemnify and keep;harmlessaat City'ofCupertino against liabilities`judgments,
costs;and expenses which may,accrue agamst,said Cit0ii,consequence ofthe
•:
:'grantf thispeFinit. Addi'tionally;,the applicant understands�and°will comply Issued by: �✓ �l�i Date: `��`�.
with all no mf-so ce;regulations per the Cupertino&4unicipaf @ode,;Section
r RE-ROOFS:
s� natur_ ate,g 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'alf new.materials for.
inspection.
❑. O WNE WB UiLDER--DECLARATION
Signature,of Applicant: Date:
I k riby'Afrm,that I-am exempffeom the Con iraetor's_Lice nse Law for-oneof
the following�two reasons- ALL ROOF COVERINGSTOABE-CLAW"A"OR BETTER
J,,as+owner of the property,ofrriyemployees.with wages+as their soleEcompensation;
will do;the work,and.therstructure is�nobintended or offered for sale;.(S-ec.7044;,
Business 8c Professions Code)
,d,as=owner of the property,am,cxclusivelycontiacting'with�.Iicensed:contractors-to HAZARDOUSMATERIALSDISCLOSURE,
;construct-the project(Sec:7044 Business&P,rofessions,CodeyI have read'the Hazardous;maferials requirements.under.Chapter 6.95 of the;
Californ a Health&Safety.Code,Sections25505,25533',;and 25534. I:will
Lhereby_aftirmxnder penalty of perjury-°one of the followiog'three maintaiwco►npliance with,the CupertinoMunicipal Code;,Ctiapter 9.121;and the
declarations: Health;&Safety'Code,Section"25532(a)_should I:store or handle.hazardous
I.haye:and will maintain a CertiNateof ConsehUto self`insureforWoiker's material;,Additionally,°sf;ould i use.equipment•or devic ,wtiich emit hazardous
Compensation,:as provided for•by Section,3700 of theTLabor Code;for the air"contaminants as"defned,by'the Bay.Aeea,Air Quality Management District'I
• perform-aricetofithework forwhich this permit is issued. will,,maintain comp iancewith the Cupertino.Municipal Code,Chapter;9.I2.and
,I havemnd will maintain Wor-ker'sCompensation Insurance;as provrded.for-by the.Health&Safety,Code;Sections:25505,25533,;and 25534.
:Section 3700,of ihe,Labor Code,for the performance of the work for-which'this
permit'''is`issued. Owner7Wauthorized;agent
3 certifythat;inthe"performance otihework,for wbich thisapermit{isFissued,I shall
not,employanyperson iaany mannerso.as,to`become;subjectto,the Worker's
Compensation.laws°of Cali forma If,;afer making this,c&tificaWof exemption;I CONST
, RUCTION LENDING.AGENCV
become subje"ct to the;Worker's'Compensation=provisions of t1ie.Labor''Code I must 1.hereby affirrn that there is a:construetion'lending agencyfor the performance:of
forthwith comply4ith suchpFovisions or this�permit shall betdeemed.revoked. works°•fo rwhich,this.permit,is'issued(Sec:,3097,CIv C:)'
:Lender's"Name
APPLICANT.-CERTIFICATION, Lend er's_Add_dress
-
I certify,thaY.Vhave,readtthis applicationand;state.thii;the�above infof-ination.is
correct:l;aiied,io comply;with all,'city�and country ordinances afid,,state laws;relating"
to.building consiruc_tion,and'hereby`autborize representatives'of.thi'sgcity:to enter
p fy p p p y p p rp ses (,We).agree'to save
indemm and keep harrrless}he Cit of Cupertino against liabilities judgments; ARCHi•TECT'S DECLARATION
upon the;above�mentioned ro erty or ms,echon u
0
costs,and ex enses'which'.ma accrue against said City,in,consequenceof the I understand my plansishall beused aspublic records.
granting 66his,permrt.Additionally,'the applicaniibridersta ids and-will comply
with`alCnon-point source regulations per the,Cupenino Municipal Code,Section Licensed,Professional
9I8`
Signature"', Date
CITY OF CUPERTINO BUILDING PERMIT
79U`II DiNG.ADDRESS: 10425.S DE-ANZA BLVD CONTRACTOR:PACIFIGGENERAL PERMIT NO'. 12050,146,
CONSTRUCTION'
0WNER'S,NA19E: 'CALI REAL ES,,ATL.LLC i IS(i CADILLAC CT DATE ISSUED: IM2/20,1'2
0=R'S,PHONE: 61048.78899 MILPiTAS,CA 95035 PHONE NO:(408)935-9233
LICENSED CONTRACTOWS`DECLARATION_ I
(J 7 BUILDiNG'P-ERMIT:INFO: BLDG" ELECT PLUMBS
Licciisc Class_ Lic.# fQ3� (Z(:/ ;v" r r
C
��� :MECH" RESIDENTIAL COMMERCIAL
Contractor, �uuL 6 � - [(Ai�?D�te I 7
Thereby affirm that,)am;licensed'und'er the provisions of Chapter 9, JOB DESCRIPTION:"1'I(RANCH 99)OF EXISTING 29;000;SQAUR[ 1 fit:f_OF
("commencing with Section°7000)of Division 3°of the Business&Professions SUPERMnRK15"i"SLACE INCI:UDING M Ii:i,:IJFGRA[jFS
Codcfand that,my license�is in full force and effect:
12/21/12 DEFERRED SUBMIT"FAL a 1,:TRASH E. CLOSURL SUBMI"fTAl.A'ND
REVISIT LOCATION,AND NEW ROOF TOP^.ODOWCONTROL UNITS]SSUED 3/1 I/13
1hereby affir,rn.under,penalty of perjury'one=of the foll'owingjhvo declarations:
l'.havcjan6will maintaih,a certificateofconsent.to'sclf-insure„for*Worker's
Compeiisation,;as provided.for by,Section 37,00 of the Labor Code,for the
performancetofthe work-forwhich,I is:.peri mil;isAsued.
I have and will maintain Workcr's:Compensation,.Insurance;as,prov,ided for by
Section 3700 ofthe Labor,Code„_for tlierperfon7nance.6f'tlie-work for which this Sq.Ft Floor.Ar.ea: Valuation S1500000
'permit-is issued, -
APPLICANT CERTIFICATIONS APN Number:35917019:10425 Occupancy,Type::
I certify thatal7iavcaread:thisrapplication and stalClhat the abov,e.information is
correct. )agree"to coiinply wiih'.alI city and county ordinances and statelaws relating
to building construction„and'hereby'authorize representatives ef-this city twenter
upon tlicabovc mcntioncd,proPerty lor'i'nspcctiorrpurposes. Qvc),ag)ee.toasave PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep I-iarmless the Cdy ofCupertiiio against Iiabilities,judgments,
costs,and,expenses.wl ich inay'accrucagainst'said City'im.,conscquence o ;the WITHIN: 180,DAYS OF PERMIT ISSUANCE-OR
granting of4his pc"rmit: Additionally,the applicant understands and"will comply 180 DAYS FROM LAST CALLED INSPECTION.
with,all noir-po tsourcc,,regulations per the Cupertino Municipal Code,Section
9.18.
Signature. Date,
issued.by: f��f Y ��� Date:
❑ OWNER-BUILDER.DECLARATION
RE-ROOFS:
.1 hereby'affirm`that 1 am exempt from the ContractoCs,License Law`for one'of All roofs shall be inspected prior.to any roofing,materiaf being installed,If a,roof is
the following;two reasons:, installed Without 11rs6obtailling-an,inspection, I agree to remove all new materials for
h,as'ow-ner,oftlic�property;;or my,employees with wages as"their'sole compensation, �iiispectiijn.
will c10 Clic,work,and the structure is not-intended or offered for sale(Sec,.7044,
Business:&,Professions Code) Signaturc:of Applicant: Date:
I,as-owner ofdhe.pr60ghy,;airs.cxalusivclyPeontracting,with liccnsc&contractors to
construct the project(Sce.7044,Business&Professions Code). ALL,ROOF'COVERINGS TO BE CLASS"A,'"OR BETTER
1_her by.affirm under°penalty of perjury one oGthe,following three
declarations:
I have and will;maintain,a.Certificate,ofConsentto self-:insure for Worker's JiA%ARDOUS MATERIALS DISCLOSURE
Coinficnsation as'provide,d„for b Scct on:3700 of the Labor-Codc„fof"clic " j"have read the:hazardons materials requirements under Chapter 6.95'�oll"the
performancc;ofathework'for Which this permit is issued, California health&:Safety Code,Sections 25505,y 25533,and;25534 . I will maintain
I,havcRand'will maintainWorker's Compensation Insurance,as provided for by compliance with the-Cupertino Municipal Co'de;,Ch"apter-9.12-,and the Health
Scetion,3:700 of the.LabdrCode,'for the performance of the work-for which this Safety Gode,;Sec'tion 25532(a).rsliouldil store or handle haiardous°material.
Additionally,should 1 usefequipment,or�devices,which emit hazardous air
permit,is issued> contaniinant,s as defined by'thc Bay Area Air Quab ,Mans ement District'1 will
Iccrt
ify that in thctperformance of;the,work for which;tliisgpermit.is°issued,I shall main' g
__ fain compliance the MunicipafCodc,ChapterQ.l'2.ind,9hc
not°employ,any person in-any inarincr�so<as tb:bceomc,subjcct to;the-WorkcCs, Health;&�Safcry Code,Sections 25505,25533,and''-
255.34.
Com penmtion.laws ofGalifornia: If,after,snaking=this,cehii1catc of'excniptioil,"I
,become=sub)cct'to tlie'Workct's Compensation proyisionsof the t,aborCode,[,;must «n 'tir"ant' ,ii :
forthwith comply'with such proyisionsw this permit shall be deemed revoked..
Date:.
APPLICANT CERTIEICA`I'ION CONSI'R XTION' LENDiNG.AGF,•NCY
I certify that,)have•read`this<application`aiid statethatthe•above information is 1 hereby'aflirm than there is a constructioii.lendiifg agency for the performance of worl:'s
correct.,)agree-to comply with all'6ty'andeounty ordinances and state laws relating "for which°this,wpermit is issued(Sec.3097;._Civ C)
to building.constructioii,.arid'aiereby.autlioiizc rcprescritativcs,of this city'to�cnter Lender's-Name,.
upon tlicrabovc.mentioiied property for inspection purposes,(We):agrec..tasavc
indemnify and keep harinlcss`the City of Cupertino against liab'ilitics;jLf nients, )tender's+Address
Cos ts 'and;cRpenses whiclvinay accruetagamsLsaid City-in,conscgiicncc 6l',ihc.
gran ng of.tliis'permii.Additionally,the:applicaiitundetstandsaand will'comply ARCHITEC"1''S DECLARATION
:wifh.all.non-point sourcerrcgul_ationsper'the;Cupertino Municipal Code;,Sec"tion
918. I'understand,my plans'slialf bcused,as public,rccords—:
�Stgna-ture Date Licensed Professio'nat
CITY OF CUPERTIN,O
FEE ESTIMATOR- BUILDING DIVISION,
ADDRESS: 10425'S.'Deanza Blvd DATE:, 12/20/2012 REVIEWED BY: Sean
APN BP#: /2050146 'VALUATION: $0
kPERMIT TYPE:, Building Permit PLAN GHK'TY
ECPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
USE: Commercial"Building PERMIT TYPE: 1 GENCOM,
WORK 1.D'eferred Submittal 41: Plan_s for construction of trash enclosure,and for the odor control units installed
SCOPE on'the roof:
` .
21
F
, 5, ", k6 at, 3
r
E3
NOTE: This estiii:ate does`not'includefees due to othgeDepdiiiiients(i e.Planiring,Public Works,Fire,.Sdnifdry,Sewer Disfr'ict„School
District,etc.):, ihese. eescare based,,on:l:e prelfininar "in ormation available,andwre onl yan estimate: Contactthe�pe t or addn'l inf&
FEE,ITEMS�(Fee Resoluti6n.11-053.Eff.`711112) FEE QTY/FEE MISC-ITEMS
;Plan Check-Fee; Hourly Only? 0 Yes ) No $0.00 ® hours Plan Check,Hourly
Suppl. PC Fee:. (F)'Reg. 0 OT 1 0, 0 hrs. $0.00 $532:00 ISTPLNCK
;PME Plan;Chedk:
Perinit.Fee: Hourly Only? Q Yes Q No $0.00
Suppl.-Insp. Eee:Q Reg. Q.OT' 00 hrs ;$0.00,
PME UnifTee
PME°Permit Fee: KOG
Work Wthot Permit? QYes' No. $0.00iut °
Q.
Advanced Planning°Fee: $0..00hours Inspections' Q
ejwI 111 -$532.00 1STINSP Inspection,Hourly Q�
;Strong Motion Fee: $0.00 Select an Administrative-Ite_m
B1dQ'Stds Corriini"sgion Fees $0,00
to
SUBTOTALS =" /� .,00. 1;,064:00 TOTAL 1, 064.00
,.. � . .a.
Revised: 10/01/201'2
'CITY'OF CUPERTINO BUILDhN.G PERMIT
BUILDING•ADDRESS: 10425:5 DE.ANZA BLVD, CONTRACTOR:PACIFIC GENERAL, PERMIT NO:.12050146. •.
CONSTRU,GTION,
OW,NER'S,NAME: CALI'REAL.ESTATELLG = =43050C.MSTYST tDATE ISSUED: 12/12/2012
OWNER'S PHONE: 5104878899. FREMONT,,CA.94538 P•HON-KNO:(510)824-0490.
LICENSED CONTRACTOR'S DECLARATION dOB DESCRIPTION: RESIDENTIAL ElCOMMERCIAL.0
License Class Lic.X. G 37 y;,Z TI,(RANCH) 9)OF EXISTING 29;000 SQAURE FE'ET`OF�^ �SUPERIMARKET SPACE; INCLUDING M:E.P;UPGRADES
• Contractor.-PCIS•lr2'/I�r��l/�A5/<Go�1�m9Date la/c��oZ'
I hereby aff�m,ttiat,I am lieensed,under the-provisions ofaChapter�9
(commencing wnf:D
ith Sectio_ 7000)oiviAbn 3"of the'Bu sioes§&,Pfofessioo's
Code:afidahat my liceo'se is in;fulI'forceaod'eff&C
I her
eby affrm'underpenalty of perjury one-of ttie;following two;declarations:
1'have:arnd'will maintain a&rtificate,ofconsen0b self-insure for"Worker's
Compensation„as provided for`by Sectiorr:3700 of the'LaborCode;;for the,
performance ofthe+work%fdf,khich this permit is issued. SgjtFloor,Aeeai Valuation:31500000
•I haveand will maintain Worker's,Compensation Insurance,as,provided for by
Section 3700',of the Labor Code,for the performance oExhe'work`.for4hich,this
APN Number:,3591,7019;10425 OccupancyType:
permitis issued
APPLICANT CERTIFICATION
l4certifythdt I have'bread`thisuapplication,and',state thatxhe±abovejnformaiion is PERMIT,EXPIRES'•IF WORK IS NOT STARTED
correct.,I`agree�to comply with all city-.and county ordinances and state'laws relating
to building'construciion;,and'hereby authonze;representativessof this cRy'to enter WITHIN.=1.80 DAYS gF'.P.ERMIT ISSUANCE'OR
upon•the above mentioned-property for inspection purposes. (Weyigfee?to•save 1.80,'D7YM LAST.CALLED:INSP,ECTION.
liiidemmfy,and keep arinfess"the City,of Cupertino against liabilities judgments,
costs and expenses which may accrueiagainstsaid City'in consequence of the,
grantingofthis permit. Additionally,the"appli'cant understands and'will comply Issued'by: Date: �' 9
with all non
PP.inUsource`Eregulations per the'Cupertino_slvtumcipal(CodeSection
9.18.
Signature /(j L/) Date All ioofs,shali'lie inspected'prioi to anyE ROOFinaterial being,instalied.,lf:a roof.i's
installed without,frst,olitaining,an,ihspeotion;I agreedo remove all new materials;for
inspection.
❑ .OWNER-BUILDER,DECL'ARATION
Signature ofApplicant. Date:
I hereby:aftiirm that I amhexemptifrom the Contractor's Lice6c Law for one of -
the followin two reasons:
g pro perty,oy pto.. yees'with g p ALL ROOF COVERINGS TO"BE.CL'ASS"A"OR[BETIER
:I,as owner,ofathe; rmdin wa es,as their sole;co"m ensation,
-
will do the work;and the-)structure is notintended or offered for sale(Sec,7,044,
"Busine'ss&Professions Code)'
,I,as'bwner of the,property,am_exclusivelycontracting with licensed,coutrac'tor-s_.to HAZARDOUS;MATERIALS DISCLOSURE,
eonstnict the pr6ject(Sec:7094 Business*&.Professions Code)., I have,readAhe hazardous,materials requirements under.Chapter 6.95 ofthe
California Health.&,Safety Codc,;Seetlons_25505,25533,and 25534 I.will
I,hereby44frm under penalty of perjuryone,.of fhe`following three;
maintain eomplian_ee�with the Cup6tino Mimi6pal;C6de,Chapter 9.f2 and the-
deelaraiions:
Health&SSafety.Code,Secti6n.25532(4)sti6uld3-store or handle hazardous
have,and will.maintain'aCertificate 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[he Labor Code;forthe airTcontaniinanWas defn_edby the.Pay.Area ArrxQuality ManagementeDis-trict;h
;performance ofthe work for which;thisrpermit is,issued. will maiuta n,comphance with theCupertino Mtmieipal Code;.,Cha0ter,9 17an&
7 have andiwdl'maintain.Worker's Compensation,Insurance,as provided for,by the-Health&:Safety.Code,Sechoos�255 ,25533,'and.25534.
'Secti6n3700 of the Labor Code;,for'tfie;performance.of the,work`foiwhiie-Wthis _ _
permit rs"issued Owner;or,authorized agent: Date: ;7
1 certify that,inbthe.performarice�ofthe work'forwhich'this„pe_rmitisrissued,'l shall
-riot employ.any person m any�_manner so as,to'become�subiect.,to,the'Worker''s”'
°Compensation Iaws,of.eahfomia. If after making this;certificdte'o_f'exemption,,1 CONSTRUCTION LENDING!AGENCY
become>subieOto the^Worker's;Compensation,provisions,of.the,LaborCode,fniust l:hereby affirm:jhattbereiis a consiruction`1'ending°agency for the performance:of
forth with,cornp
Le der s
ly with such;provision"swor tfii's,permit shall be deemed revoked, r which this permit-i's issued(Sec.3097;Civ,C')
APPLICANT.CERTIFICATION Leniler',s Address
I_certify:that 1 have read'tfiis ojiolicaiion and statethat the aboveinformation'is:
correct-A agree to comply with&.city and county`ordinances',and,state laws relatipg
to,building constiuctiou,an&hereby;authorize representatives of thissci y to enter,
upon tbefab.ove,-mentioned propery_for inspection_purposes!.(We)agree to,save
ities p ment
s; ARCHITECT'SMECLARATIONindemnify"andkeep hmless he Ci h'of Cupertino a ainst habiI .
costs„andexpdnses4whi6h'may,4c!;Me against said City in.('--se
— uence'of the I'understand_my pfans^shall be used as;public records.
granting of this permitAdditionally;tfie applicant understands and:.will comply
with alhinon point+source regulations°peg,the Cupertino„Municipal Code,Section. 'Licensed Professional
9.18'
Signature ,Date
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION L&
ADDRESS: 10425 So;:De Anza Blvd DATE: 06/118/2012 REVIEWED"BY: Sean,
APN: BP#: *VALUATION'. 1$'1,5001000
-PERMIT'TY' PE-, Building Permit PLANCHECK TYPE! Tenant Improvement.
Commercial al Buildin PENTANIATION
rn1MTI
USE: - PERMIT TYPE:
Tenant Improvement of 20000 sq ft for new 99 Ranch Market.
SCOPEF
TYPE OF FLR AREA
OCCUPANCY- TYPE-. CONSTR. &L) PC FEES' PC PEE 16 BP FEES 13P FEE ID
,-.— (
29,000 IVCK $1 0�;661.8 1 0 IMTHNSP
,M (Tenant Improvements) V-13
41,229.2.0 J'AITIPL
M,FT,
,TOTALS: 29j000 so
:$4j22 10 $10561 ' gg
80 1§10 ,
I I M-MI A.
9 ME
fuot 5, 1
-q-D
I No
YN 5, ap IYes Q
M�
ON
ft '3
UM",f 0 41
�,V, AN,
IN T 9F
ivfcc/i; filar(.,heck 1911u;lL> 177�;,? hc(i, Elec. P:ria ChCck
Ce.,
Fwe�, W
Ott
tech.M.SP� M !);
EL �j
NOTE;-Thisesdindte does not�.inchidefees duetowher,Departments(i.e.Planning,Public Works,Fire,,Sanitayy,SewerDistrictj School
;District;ei&)� ;These- are.,based on the,�relimid. fna 4nformation-available anare J I-—2 n-- estimate. Cohtai�tthe,Dg�pt.fbiiiddn?li'nfb..
FEE ITEMS (Fee Resolution 17 E,#.'-053 711,11QTYXEE
1) FEE MI$C ITEMS
. y
Plan Qb-eqk,.Fee: $42029.20 Select a Misc Bldg/Structure
'Suppl.,PC,Fee: 0 Reg; Oor Element:6fa,BuildinaOT 0.0� hfs $0.00 A
OME Plan Check: $0.00
Permit Fee, $10,561-'80,
,Suppl.,,In .FeeG,_iftOT, 0 0 hr5 $0.00
-�p
', 'C), .
PME.Unit Fee:.
PME Permif Fee:= .0
'Work Without Permit? 0 Yes E) No $0,00 E)
AWvancod'Planning $Q;00 Select a Non-Residential
E)
Building or Structure
,Sirong,Motion Fee'- IBSEISMICO $3'15:,0a Select anAdminis trative Item
1-
Bld�'Stds',Com rn'iss ion Fee: 1BC-BX1 $,60:00
766.00 $0.06TOTAL FEE'S $
Revised: 04/01/2012