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11080072 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11010N DE ANZA BLVD CONTRACTOR: PERMIT NO: 11080072 OWNER'S NAME: CUPERTINO DE ORO CLUB INC A n►-s C ` DATE ISSUED:08/09/2011 C ""NER'S PHONE: 8016021426 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class �� Lic.# �G/� G ys / MECH f— RESIDENTIAL COMMERCIAL Contractor _ 04""kl Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CHEVRON-INSTALL ELECTRICAL RECEPTACLE FOR (commencing with Section 7000)of Division 3 of the Business&Professions BLOCKBUSTER VENDING MACHINE USING GFCI-WR 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 Sq.Ft Floor Area: Valuation:$400 permit is issued. APPLICANT CERTIFICATION APN Number:30942041.11010DEANZA Occupancy Type: 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 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 FROM LAST CALLED INSPECTION. with all non-point source a per the Cupertino Municipal Code,Section 9.18. _ 19' 1 Issued by: Date: Signat 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 I,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(See.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 I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 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 I 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 Owne r aut orize ent: forthwith comply with such provisions or this pen-nit shall be deemed revoked. Date: �3 / APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I 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 c and expenses which may accrue against said City in consequence of the ig of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 13 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 30942041. 11010DEANZA DATE ISSUED. . . . . . . : 08/09/2011 RECEIPT #. . . . . . . . . BS000014367 REFERENCE ID # . . . : 11080072 SITE ADDRESS . . . . . : 11010 N DE ANZA BLVD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : CUPERTINO DE ORO CLUB INC ADDRESS . . . . . . . . . . : 11010 N DE ANZA BLVD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ORAN BLAUSTEIN CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1.00 41. 00 0. 00 41 .00 0 . 00 1BCBSC VALUATION 400 .00 1. 00 0 . 00 1.00 0. 00 1BREMRECEP NO. OUTLETS 1. 00 44 . 00 0. 00 44 . 00 0. 00 1BSEISMICO VALUATION 400 .00 0. 50 0. 00 0 .50 0. 00 1EPERMITFE FLAT RATE 1. 00 44 . 00 0. 00 44 . 00 0. 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0. 00 44 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 174 .50 0. 00 174 .50 0 . 00 GENERAL PERMIT APPLICATION - - MEP - LQ COMMUNITY DEVELOPMENT DEPAR T MENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINC! (408)777-32228 • FAX (408)777-3333 • buildinG(a.cuDertino.crg MISC ❑PLUivlBING ❑!MECHANICAL ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS //O/O . J' Q J✓ APN OWNER NAME1 _ PHONE g 1 �(�21 12 E-MlijL //T STREET ADDRESS G 2 l I C , STATE,ZIP FAX .D9 U"C CONTACT NAME f\ PHONE E-MAIL (�r STREET ADDRESS CITY,STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT E0r0NTRAC70R ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ Tu]A,NT CONTRACTOR NAMEn!M 1 Q�n f LICENSE NUMBER I/bG` LICENSE TYPE`/ BL'S.LIC COMPANY NAME (�n E-MAIL FAX STREET RIT t `C # CITY,STATE,ZIP PHONE i �v�cr' C_ t / g'J$ ZCoCo •03l ARCHITECT/ENGR4EER NAME LICENSE NUMBER BUS.LIC 4 COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF ❑SFOaTI r DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDIAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN Cl YES BUILDING: PIIvIERCIA.L URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK ICS 1(� t -L-J -- W/Z. TOTAL VALUATION: �G RECEIVED BY: � By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is et.,.have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ' a nstructi n.'I authorize representatives of Cupertino to enter the above-idennttilied property for inspection pu£poses. Signature ofApplicant/Agent: Date: 47• / -1/ SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY ET THE-COUNTER ❑ EXPRESS Y U ❑ STANDARD U ❑ LARGE ❑ MAJOR 11E,P,11rsc-4pp_2011.doc revised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 11010 n, de anza blvd DATE: 08/09/2011 REVIEWED BY: bobs. APN: I BP#: 'VALUATION: $400 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY Commercial Building PENTAMATION 10EAP10 USE: I I PERMIT TYPE: WORK install electrical switch/receptacle for vending machine. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Recep/Switch/Outlets 1BREMRECEP 1 # $44 TOTALS: $44.00 Elec.Plan Check 0.0 hrs $0.00 Elec.Permit Fee: IEPERMIT 77 Other Elec.Insp. 0.0 hrs $44.00 I-- NOTE. These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS (Fee Resolution 11-053 Is '. 1.-ll) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong- Motion Fee: 1BSEISMICO $0.50 0.5 hrs Admin./Clerical Fee Bld)Stds Commission Fee: 1BCBSC $1.00 $41.00 1ADMIN SUBTOTALS: $133.50 $41.00 TOTAL FEE: $174.50 Revised: 07/04/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 .;U PERTI NO Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: /��/O .� 'InZ v PERMIT# .� OWNER'S NAME: (�$19 PHONE# 15 • ZZ Co C� � GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SU CONTRA TORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. g I am not using any subcontractors: / l/ Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum /Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date