12050090CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10590 S DE ANZA BLVD
CONTRACTOR: NT GENERAL
PERMIT NO: 12050090
CONSTRUCTION CO
OWNER'S NAME: BYER PROPERTIES LP
1351 NORMAN DR
DATE ISSUED: 05/08/2012
OWNER'S PHONE: 4156262937
SUNNYVALE, CA 94087
PHONE NO: (408)623-2297
❑ LICENSED CONTRACTOR'S DECLARATION
r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie. # b �Q
f
MECH RESIDENTIAL COMMERCIAL
Contractor
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: TAIJI MEN QIGONG ACADEMY - 3180 SQFT TENANT
(commencing with Section 7000) of Division 3 of the Business & Professions
[MPROVEMENT.ADD TWO ACCESSIBLE RESTROOMS, NON
Code and that my license is in full force and effect.
BEARING DEMISING WALLS, ELECTRICAL AND HVAC
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
Sq. Ft Floor Area:
Valuation: $65000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. .
APPLICANT CERTIFICATION
APN Number: 36938037.10590
Occupancy Type:
[ certify that 1 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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will comply
180 DAYS ROM LAST CALLED INSPECTION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date_��%�
ed y� Issu° Date:
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
Signature of Applicant: Date:
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1 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
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District 1 will
I certify that in the performance of the work for which this permit is issued, I shall
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Health & Safety Code, Sections 25505, 25533, and 25534.
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
Owner or au d agent:
Date:�l��a
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
1 hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
ARCHITECT'S DECLARATION
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
F FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10590 s. de anza blvd
DATE: 05/08/2012
REVIEWED BY: larry s
APN:
BP#:
'VALUATION:
1$65,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE:
PENTAMATION 1 B TI
I PERMIT TYPE:
WORK 13180
sq ft tennant improvement. add two accessible restrooms non bearing demising walls electrical
SCOPE I
and hvac. 0
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.L
PC FEES
PC FEE ID
BP FEES
BP FEE ID
B (Tenant Improvements)
II-B,III-B,WN-B
3,180
$2,174.60
IBTIPLNCK
$2,532.48
IBTIINSP
TOTALS:
3,180
1 $2,174.60
1
$2,532.48
MECH, HOURLY Q Yes (j) No
PLUMB, HOURLY % Yes Q No
ELEC, HOURLY 0 Yes Q No
Llech. Plan Check
Plumb. Plary Cnoc•k
Elec. Plan Chcck
ec:h l"'rmil Fee:
limb. Pelmi/ Fee:
I:le(.. Pcr,nfr Fee:
Oil)o Afe(h. Ins1).
0111cr Plumb Imp
0111er Occ. Y ,I
W(J, In;p. h',�
Plvnrb. h?sl). F<e.
Elec_ 117sp. Fee.
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the Dreliminary information available and are only an estimate. Contact the Dent for addn'1 into.
FEE ITEMS (Fee Resolution 11-053 E . 711111)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,174.60
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: Q Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$2,532.48
Suppl. Insp. Fee-.0 Reg. Q OT
0 0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax.
rl dm w i.swatNe .Fec.
Q
E)
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee.
$0.00
Select a Non -Residential
Building or Structure
0
i
0
Travel Uocninentation Fcces:
Strony, Motion Fee: IBSEISMICO
$13.65
Select an Administrative Item
Bldg_Stds Commission Fee: IBCBSC
$3.00
SUBTOTALS:
$4,723.73
$0.00 TOTAL FEE:
1 $4,723.73
Revised: 04/01 /2012