11080194CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21265 STEVENS CREEK BLVD CONTRACTOR:
OWNER'S NAME: MODENA INVESTMENT L.P.
OWNER'S PHONE: 4083916798 ,
❑ L ENSED CONTRACTOR'S DECLARATION
License Class Lic. #
L , /
Contractor / (� Date vQ�
12
I hereby affirm that I am licensed under the provisions of �apter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
PERMIT NO: 11080104
I DATE ISSUED: 08/12/2011
PHONE NO:
BUILDING PERMIT INFO: BLDG. Ir- ELECT r PLUMB r
MECH F RESIDENTIAL F COMMERCIAL r
JOB DESCRIPTION: STE 230 - REPLACE YOGURT EQUIPMENT NO
ELECTRICAL,
ADD NEW WATER SUPPLY
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. Sq. Ft Floor Area:
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 non7po, t source regulation a Cupertino Municipal Code, Section
9.18. J
Signature DateF, /�7_
❑ NER-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 (Sec.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.
Valuation: $800
APN Number: 32627035.21265 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued b. Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material berg 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. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should 1 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 25505, 25533, and 25534.
t'� or'ent: /
Dater /
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of wrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Add
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date
Licensed
CITY OF CUPERTINO
FM_7 FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21265 stvns crk blvd.
DATE: 08/12/2011
REVIEWED BY: bobs.
APN:
BP#:
"VALUATION:
$800
%PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building71
USE:
PENTAMATION 1CMAP1
PERMIT TYPE:
WORK
lace yogurt equipment no electrical add new water supply..
SCOPE
�re
Mech. Plan Check 0.0 1 hrs $0.00
Plumb. Plan Check 0.0 hrs $0.00
Mech. Permit Fee: IWERMIT
Plumb. Permit Fee: IPPERMIT
c. r' : r-: "'
0.0 Other Mech. Insp. hrs $44.00
Other Plumb Insp. 0.0 hrs $44.00
1 ire:�t-r:. i �s
NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711111)
FEE
QTYIFEE
MISC ITEMS
Plan Check Fee:
$0.00
0 #
$65.00
Mechanical
1BAPPLOT Other Appliance/Equip
Suppl. PC Fee: 0 Reg. 0 OT
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
0 # Plumbing
$9.00 IBPFIXTURE I Fixture or Trap
Permit Fee:
$0.00
Suppl. Insp. Fee-.0 Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$88.00
Acoustical Fee: 0 Yes E) No
$0.00
0
0
Work Without Permit? 0 Yes G No
$0.00
Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
Q
0
Travel Documentation Fee: ITRAVDOC
$44.00
Strony, Motion Fee: 1BSEISMICO
$0.50
0.5 hrs
$41.00
Admin./Clerical Fee
IADMIN 1
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$133.50
$115.00
TOTAL FEE:
$248.50
Revised: 07/04/2011