12110027CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21646 STEVENS CREEK BLVD CONTRACTOR: AN KY CONSTRUCTION, PERMIT NO: 12110027
INC.
OR'NER'S NAME:
1 SAN JOSE, CA 95139 1 PHONE NO: (408)234-2673 1
❑ LICENSED CONTRACTOR'S DEC�L)'ARATION
License Class_ /3 Lie. #
Contractor �/j/ �/ /�7112(%Clj(�y Date f
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.
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
permit is issued.
APPLICANT CERTIFICATION
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
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 permit. Additionally, the applicant understands and will comply
with all non -point source regu ions pe he Cupertino Municipal Code, Section
9.18.
Signature Date If /✓L Z
❑ OWN,R-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 (See.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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
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 permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18,
Date
BUILDING PERMIT INFO: BLDG F ELECT r PLUMB f
MECH r RESIDENTIAL F COMMERCIAL I
JOB DESCRIPTION: PASSIONS NAIL & SPA - 133 SQFT CONVERTING OPEN
SPACE TO OFFICE AND BREAKROOM.INSTALL NEW HEAT
PUMP, ADD 2 FOOT SINKS AND 10 LIGHT FIXTURES
Sq. Ft Floor Area: I Valuation: $12000
APN Number: 35717010.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Date
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 505, 25533, and 25534.
Owner or
.� � Date:,
/ //C —
ONSTRUCTION
LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY. TYPE:
DDRESS: 21646 Stevens Creek Blvd
DATE: 11/05/2012
REVIEWED BY: RDW
W
PN:
BP#:
*VALUATION: $12,000
PE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
Commercial Building
IBTIPLNCK
PENTAMATION
1 B T'A
USE:
Ekc. Mslz Fee:
PERMIT TYPE:
WORK 1133
sq/ft converting open space to office and breakroom. Install new heat pump. Add 2 foot sinks and
SCOPE 110
light fixtures.
OCCUPANCY. TYPE:
TYPE OF
FLR AREACONSTR. s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
B (Tenant Improvements)
II-B,III-B,IV,V-B
133
$1, 0.00
IBTIPLNCK
$547.00
IBTIINSP
Ekc. Mslz Fee:
$0.00
I L I #
$20.00
",21�1) D -D
Permit Fee:
$547.00
Suppl. Insp. Fee:Q Reg. Q OT0.0
hrs
$0.00
10 Electrical
$67.00 IBREMFIXT Fixtures, Lighting
PME Unit Fee:
$0.00
PME Permit Fee:
$135.00
Construction Tax:
TOTALS:
133
$1,950.00
$547.00
e
MECH, DOURLY 0 Yes G No
PLUMB, HOURLY ®, Yes (F) No
ELEC, HOURLY ,i ® Yes Q No
Mech. Plan Check 0.0 hrs $0.00
Plumb. Plan Check 0.0 1 hrs $0.00
Elec. Plan Check 0.0 1 hrs $0.00
Mech. Permit Fee: IMPERMIT
Plumb. Permit Fee: 1PPERMIT
Elec. Permit Fee: IEPERMIT
Mech. Insp. 0.0 hrs $45.00
Other Plumb Insp. El hrs $45.00
Other Elec. Insp. 0.0 �rs$45.00
LOther
. Lisp. Fee:
Plrnulz Insp, Fee:
Ekc. Mslz Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, Scoot
Divtrint etc) Thew franc are h/7.Ced an tho nroH»tinary information available and are on1v an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 711112)
FEE
QTY/FEE7--
MISC ITEMS
Plan Check Fee:
$1,950.001=
#
$133.00
Mechanical
IBCAIRHA Heat Pump (<=10K cfm)
Suppl. PC Fee: (j) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
I L I #
$20.00
Plumbing
IBPFIXTURE Fixture set on One Trap
Permit Fee:
$547.00
Suppl. Insp. Fee:Q Reg. Q OT0.0
hrs
$0.00
10 Electrical
$67.00 IBREMFIXT Fixtures, Lighting
PME Unit Fee:
$0.00
PME Permit Fee:
$135.00
Construction Tax:
A(hilinistral Ne 1 c L':
e
Work Without Permit.
0 es Q No
$0.00
Advanced Planninglee:
$0.00
Select a Non -Residential
Building or Structure
i
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee:
IBSEISMICO
$2.52
Select an Administrative It
Bldg Stds Commission Fee: IBCBSC
$1.00
_77SUBTOTALS:
$2,680.52
$220.00
TOTAL FEE:
$ , 00.52
Revised- 10/01/2012
NN
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
ADDRESS: 21646 stvns crk blvd
DATE: 11/06/2012
REVIEWED BY: bobs.
PC FEE ID
APN:
BP#:
*VALUATION:
1$12,000
%PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
USE: Commercial Building
$0.00
PENTAMATION
PERMIT TYPE: 1 B T�
WORK
Code Enforcement Case:
[ig-Q!Par
SCOPE
Other Elec. Insp. 0.0 hrs $45.00
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
B (Tenant Improvements)
II-B,111-B,IV,V-B
0
$0.00
Plumb. Permit Fee: IPPERMIT
$0.00
Other Mech. Insp. 0.0
�rs$45.00
Other Plumb Insp.0.0 hrs ]_$45.00
0 #
$23.00
Other Elec. Insp. 0.0 hrs $45.00
Alech. Insp, Fee:
Permit Fee:
Phnnb. hap. Fcc:
Suppl. Insp. Fee -.(F) Reg. Q OT
Elec. Insp. Fee: €
1 hrs
$0.001=
# Plumbing 4
$23.00 IPCSEWER Sewer, Sanitary
PME Unit Fee:
$0.00
PME Permit Fee:
$135.00
= # Mechanical
$133.00 IBCAIRHA Air -Handling (<=10K cfm)
Construction Tax:
TOTALS:
0
$0.00
10 ##
$67.00
$0.00
0
G
MECH, HOURLY 0 Yes
G No
PLUMB, HOURLY ®;Yes
E) No
I ELEC, HOURLY ® Yes Q No
Mech. Plan Check0.0 hrs
$0.00
Plumb. Plan Check 0.0 hrs
$0.00
Elec. Plan Check 0.0 1 hrs $0.00
Mech. Permit Fee: IMPERMIT
Plumb. Permit Fee: IPPERMIT
Elec. Permit Fee: IEPERMIT
Other Mech. Insp. 0.0
�rs$45.00
Other Plumb Insp.0.0 hrs ]_$45.00
0 #
$23.00
Other Elec. Insp. 0.0 hrs $45.00
Alech. Insp, Fee:
Permit Fee:
Phnnb. hap. Fcc:
Suppl. Insp. Fee -.(F) Reg. Q OT
Elec. Insp. Fee: €
NOTE This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etr-). These fees are hosed an the nreliminary information availahle and are only an estimate. Contact the Dent for addn'I info.
FEE ITEMS (Fee Resolution 11-053 Eff 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
® If
$467.00
Interior Partitions
IPARTICOMM
i
Suppl. PC Fee: Q Reg. OT
0.0 1
hrs
$0.00
PME Plan Check:
$0.00
0 #
$23.00
Plumbing
1 IPCSEWER Sewer Building
("
Permit Fee:
$0.00
Suppl. Insp. Fee -.(F) Reg. Q OT
1 0,0
1 hrs
$0.001=
# Plumbing 4
$23.00 IPCSEWER Sewer, Sanitary
PME Unit Fee:
$0.00
PME Permit Fee:
$135.00
= # Mechanical
$133.00 IBCAIRHA Air -Handling (<=10K cfm)
Construction Tax:
Achninistralh.,e Fee:
10 ##
$67.00
Electrical
1BIEMFIXT Fixtures, Lighting
0
G
Work Without Permit? (D Yes 0 No
$848.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
G
0
i
Travel Documentation Fee: 1TRAVDOC
$45.00
Strong Motion Fee: IBSEISMICO
$2.52
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:`
$1,031.521
$713.00
TOTAL FEE:
1 $1,744.52
Revised: 10/01/2012