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15080205R CITY OF CUPERTINO BUILDING PERM IT BUILDING ADDRESS: 19800 VALLCO PKWY CONTRACTOR: LAYTON PERMIT NO: 15080205 CONSTRUCTION OWNER'S NAME: CUPERTINO PROPERTY DEVELOP LLC 9090 S SANDY PKWY DATE ISSUED: 08/28/2015 OWNER'S PHONE: 4083431088 SANDY, UT 84070 PHONE NO: (949) 429-6740 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL ❑ REPAIR COUPLINGS IN GAS LINES FOR RETAIL SPACES License Classyr Lic. # 7 95-2 3 AT Contractor �1Lw1 (?W,T6Ch_MDate � $%r 2 SW AND NE OF PROPERTY. 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 Sq. Ft Floor Area: Valuation: x->uun performance of the work for which this permit is issued. 1 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 APN Number: 31620108.19800 Occupancy "I ype: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Issued by: �E��✓ Date: granting of this Additionally, appl' ers ds and will comply / i`7� �1 with all non oint sour a re io pe up mo nicipal Code, Section RE -ROOFS: 9.18. p / Signatur Date 2 ` `5 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. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: 1 here affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quali nagement District I performance of the work for which this permit is issued. will maintain compliance with pert' M I C e, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, S tions 55 , a 25 4. Section 3700 of the Labor Code, for the performance of the work for which this • Owner or authorized agen Date: 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 CO RUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CUPERTINO GENERAL PERMIT APPLICATION mmm E mv COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildino(aDcUoertino.ora m/�jD��DLj Al'fPA7iscApp_2011.doc remised 06121/11 m �,—��,�CITY OF CUPERTINO 1 *�"�(�/.I FF,F. F.4TIMATOR — BUILDING DIVISION ik-NI ADDRESS: 19800 Vallco Parkway DATE: 08/28/2015 REVIEWED BY: Sean UNITS APN: BP#: 'VALUATION: 1$25,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair T-1 PRIMARY SFD or Duplex $72 PENTAMATION 1 RPGA USE: PERMIT TYPE: WORK air cou lin s in gas lines for retails aces at SW and NE of property. �Re SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 hrs $0.00 QTY UNITS BP FEES Elec. Permit 1,ec Piping, Gas <=4 Outlets 1 PGASRES Ocher Elec. Insp. 1 # $72 Permit Fee: Srt,r>pl, Insp Fee PME Unit Fee: $72.00 PME Permit Fee: $48.00 Construction 7nx: Administrative Fee: ]ADMIN $45.00 Work Without Permit? ® Yes 0 No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $72.00 Stroniz Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public works, tire, SanitaryN er mstrtet, Schoot n.os.int ntn 1 Tit— fb nro hneod nn tho nroliminary inlnrtnatin" ovailahlo and are anly an estimate Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11-053 E . 711113) ;ttech. Plan Chea Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check Afech. i Plumb. Permit Fee: IPPERMIT Elec. Permit 1,ec Other Alech. Insp Other Plumb Insp. 0.0 hrs $48.00 Ocher Elec. Insp. 14ech. Insp. Hee: Ihuub. hup. Fir: Eley. Insp. Hee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public works, tire, SanitaryN er mstrtet, Schoot n.os.int ntn 1 Tit— fb nro hneod nn tho nroliminary inlnrtnatin" ovailahlo and are anly an estimate Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Srt,r>pl, Insp Fee PME Unit Fee: $72.00 PME Permit Fee: $48.00 Construction 7nx: Administrative Fee: ]ADMIN $45.00 Work Without Permit? ® Yes 0 No $0.00 ,ldvanced Planning Fees: Travel Documentation Fee: ITRA VDOC $48.00 Stroniz Motion Fee: IBSEISMICR $3.25 Select an Administrative Item BldgStds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $217.25 $0.00 TOTAL FEE: 1 $217.25 Revised: 07/02/2015