10120145CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10615 S DE ANZA BLVD I CONTR C OR; PROVISION I PERMIT NO: 10120145
OWNER'S
License Class Lic. # C
Contractor i?JW) Sf0d-4 Date L' % CP'ZP f 1
I
I hereby affirm that I am licensed under the provisions of Ch pter 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:
1 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 lia ' 'ties, judgments,
costs, and expenses which may accrue against sai sequence of the
granting of this permit. Additionally, th ican erstands and will comply
with all
/ O ,° %
❑ 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,
��
ate:
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Date
Licensed Professional
CITY OF CUPERTINO BUILDING PERMIT ; �3TE �i
BUILDING ADDRESS: 10615 S DE ANZA BLVD I DEVELOPMENT, INC. OVISION I PERMIT NO: 10120145
OWNER'S
1 SUNNYVALE, CA 94086 1 PHONE NO: (408) 245-0991 1
❑ LjIICCENSED CONTRACTOR'S DECLARATION
License Class f/ Lie. # _��
Contractor 00V t MG Date
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 agains ities, judgments,
costs, and expenses which may accrue agains ity ' nsequence of the
granting of this permit. Additional appIic erstands and will comply
with all
�i
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, 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)
1, 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 inform ron 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.
BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB r—
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: SUITE C, 50 SF, ALTER EXISTING BUILDING WITH NEW
T-BAR CEILING, NEW LIGHTING, ONE DEMINSING WALL,
ONE STORAGE ROOM, MODIFY DIFFUSERS, REPLACE ONE
3/2/1 1- REV# 1- ADD TWO WALLS FRO A ROOM & ADD 2 WALLS IN RESTROOM
FOR STORAGE-3/2/11 REV# I ISS'D OVR COUNTER
Sq. Ft Floor Area: I Valuation: $12000
APN Number: 35918044.00 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. 1 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 Cupert' icipal Code, Chapter 9.12 and the
Health &Safety Code, Sectior , 25533, and 25534.
Y
Dater
CONSTRUCTION LENDING AGENCY
1 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
Signature Date
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10615 s de anza blvd. suite c
DATE: 12/20/2010
REVIEWED BY: bobs.
APN: "/ C C7 y
BP#: 101 4
`VALUATION:
$12,000
*PERMIT TYPE: Building Permit I PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE:
TOT. -It,
FLOUR .4RF,4.
PENTAMATION 16 TI
PERMIT TYPE:
WORK
SCOPE
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
B (Tenant Improvements)
II-B,III-B,IV,V-B
50
$1,856.00
IBTIPLNCK
$520.00
IBTIINSP
TOTALS:
50
1 $1.856.00
1 $520.00
MUCH, HOURLY 0 Yes Q No
PLUMB, HOURLY 0 Yes D No
ELEC, HOURLY 0 Yes Q No
Mech. Ilan Check
phemh. P/o.I Chcch
hlec, Plan Ch(!ck
tech. Permit Fee:
Pllunl). Po -mil Fec"
Cle6_ Nrg7ir
Other :liech. Insp.
Orho- p/,uair Li
Ocher Elec..Insp. Li
Akch. lmp. Fee:
Plrnnb. /rsp. Fre
lslcr. Insp. Pcc,
NOTE: These fees are based on the nreliminary information available and are onlv an estimate. Contact the DeDt for addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Eff. 7/1/10)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$1,856.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: 0 Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$520.00
Suppl. Insp. Feed Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax
Acoustical Fee: 0 Yes 0 No
$0.00
0
0
Work Without Permit? 0 Yes 0 No
$0.00
Planning Fee: PLLONGRNGC
$0.00
0
Travel Docomenlalion Fees:
Strong Motion Fee: IBSEISAfICO
$2.52
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$2,379.52
$0.00 TOTAL FEE:
$2,379.52
Revised: 12/07/2010