12120084CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10990 N STELLING RD CONTRACTOR: ELK GROVE BUILDERS JPERMITNO:12120084
INC
OWNER'S NAME:
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor r�t fZ Ll`' �U/1�f�i'i Date %
I hereby affirm thatI 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 properly 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
grantIing'of this permit. Additionally, the alp t understands and will comply
with all non point sourcgtita`ti s per the pertino Municipal Code, Section
9.18..:
Signature i/6
❑ OWNER -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.
9918 KENT ST STE 1 DATE ISSUED: 01/16/2013
ELK GROVE, CA 95624 PHONE NO: (916) 685-1100
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALS
PARTIAL DEMOLITION FOR FUTURE TENANT AND
STRUCTURAL IMPROVEMENTS (SEE 12080116) AT
MCDONALDS (4,682 SQ FT).
Sq. Ft Floor Area: I Valuation: $50000
APN Number: 32609051.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 0 DAYS OF PERMIT ISSUANCE OR
180 DAY M 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 Cu��44er ' o Muni 'pal Code, Chapter 9.12 and
the Health &Safety Code s�15505, 553 nd 25534.
Owner or authorized agent: Date: : 0
CONSTRUCTION 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
Signature Date
CITY OF CUPERTINO
ro—m—N7 FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10990 n. stelling rd.
DATE: 12/17/2012
REVIEWED BY: bobs.
APN:
BP9: �
*VALUATION:
1$50,000
"PERMIT TYPE: Demolition Permit
PLAN C.'11E(.'K T)'PE:
PRIMARY
USE: Commercial Building
PENTAMATION
PERMIT TYPE: 1COMMLDE
WORK
demo Comm restaurant bldg.
SCOPE
FEE ID FLR AREA
s.f.
1DEMOCOM 4,682
Xlech, Plan Check
Ptunrb. Plun Check
Elect- Plan Check
ifech. Permit Fee:
Phnrrb. Permit Fae;
Nee. Permit 1w:
r rbtech hashCT--1_
Other Plumb h7sp.
Other Elec. Imp.
h. hayp Fcc:
L
Phmrh, Cusp, Fee:
Elee, Insp, Fee:
NOTE: This estin:ate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Il t...,.f s- 1 ri......, r—, — Anon// — M.o nraliwiann, iN fn rnlntinn availnhle and are nnly an esdinate. Contact the Dew for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
i
,Suppl. PC Fee
FA
Phnnh.lil,fech./Elec
Permit Fee:
$800.00
Suppl. Insp. Fee:(D Reg. Q OT
0,0
his
$0.00
Phnnh./11Icc:Ir,/Flee
Phnr)h./jblech,/Elee Permit Fec:
Consirlrction Too:
Aclrnilristrative Fee:
Gf"ork Mthont Perivit!
Adv(mce(l PloPn ing Fees:
Trm,el Docomentution Fees:
Strong Motion Fee: IBSEISMICO
$10.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$2.00
SUBTOTALS:
$812.501
$0.00 TOTAL FEE:
$812.50
Revised: 10/01/2012