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15090133-DP10971 N WOLFE RD 15090133 F/P CUPERTINO VILLAGE LP SCANNED BOX #663 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10971 N WOLFE RD I BUILDERS INC CTOR: ALLIED CONSTRUCTION I PERMIT NO: 15090133 OWNER'S NAME: CUPERTINO VILLAGE LP 1 875 MAUDE AVE #1 1 DATE ISSUED: 09/21/2015 1 OWNER'S PHONE: 3102790088 1 MOUNTAIN VIEW, CA 94043 1 PHONE NO: (408) 440-6168 1 a LICENSED CONTRACTOR'S DECLARATION License Class ��' Lie. # 5—,2o 8 Contractor 442d 00 / 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: 1. 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. 2. 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 liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands mid will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. 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) 2. 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: 1. 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 JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ TOFU PLUS - T.I. PREP, 2866 S.F., INTERIOR ONLY, NONSTRUCTURAL Sq. Ft Floor Area: I Valuation: $3500 APN Number: 31605051.10971 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS F - M D INSPECTION. yDate: Z� 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 rise 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. performance of the work for which this permit its issued, 2. I have and will maintain Worker's Compensation Insurance, as provided for by Owner authorized agent: Section 3700 of the Labor Code, for the performance of the work for which this Date: permit is issued, 3. 1 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 1 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. r nvemnlrr`rr"N I RNI\IMr_ ar'_IT 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - build! ng(a),cuuertinc.org CUPER71N0 /1�1 /S/ �Z El NEW CONSTRUCTION ElADDITION . El ALTERATION / TI ❑ REVISION / DEFERRED OIUGVMAL PERMIT'S PROJECT ADDRESS /Oq / Id"I APNI L ®` OWNERNAM° /A'� 1 E-MAIL Y`N ONE �^ ' STREET ADDRE- 33 L/ l CRV cre rc�i �Y ® Uh i?ry FAX r/ vV, CONTACT NAME 'l�nl ( t�/ ✓ ( (%I it PHONE 'fD9 6q) - JDro E-MAIL I STREET ADDRESS -- �j5_ F(�..�f�ts�fct.�,., CITY TATE, ZIP UI _��J %'a Jyi�ys' FAX OWNER 13 OWNER -BUILDER ❑ owNrER AGENT ❑ CONTRACTOR ❑ CONPRACTORAGENT ❑ ARCIETECT ❑rrriii'ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME /ea I LICENSENUK11FR � /�� ,ICENSETYPE J L b BUS LIC qq/ COMPANY NAKE ale / LUY S'�yrn�=/)'D,.�.- cl EMAIL f)��% FAX STREET ADDRESS q q C[TY, STATrE, ZiP jJ �"lClsretG f/e.ce - ( f'%T.t✓!- Y, llir.'U% PHONE M� ARCHITECT/ENGINFER NAME LICENSE NUMBER BUS. LTC d COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OP WORK FJIISTMG USE. — PROPOSED USE, CUNSTR'fYPE PSTORIES USE TYPE 1 OCC. SQ.FT, VALUATION(S) BXTSTO NEW FLOOR DEMO TOTAL AREA AREA AREA 9,9/ NET AREA ,. BATHROOM KITCHEN OTHER - REMODELAREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTALDLCK/PORCHAREA GARAGEAREA: LJ DETACH ❑AT ACH C DWELLING VNTTS: IS A SECOND UNrr ❑YES SECOND STORY ❑7'ES _-- BEING ADDED? 'KNO ADDITIDN7 �(:NO PRE -APPLICATION ❑YES TYES, PROVIDE COPY OF PLANK ICAPPL- PLANNE G APPROVAL LETTER ISTHEHLUGAN EICHLERHOAIEP ..ISM z - - TOTAL VALUATION; ❑NO No By my signature below, I certify to each of the following: I am the property owner or authorized agent toyg property owner's behalf. I have read this application and the, infbmlation I have provided is correct, I have read the Description ofWork and YE is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -/Id entifI d property for inspection purposes, S ignature ofApplicant/Agent _ Date: �1/mil i1 f o SUPPLEMENTAL IN ORMATIOND - - ' 'n' PT-QT C7�CK�',IPE--�I�'*� - ' >_=� - - . s ..��rOITI'LNGSLTP �.��1 New SFD or Multifamily dNVellings: Apply for demolition permit for je "❑ BIIII.DLYPLaN REY3£N existing building(s). Demolition permit is required prior to issuance of building - permit for new building. _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure form if any Iazardous Materials are being used as part of this project..-_- _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application, g�©aTA3ox "" sn�r`rr_. s�E�s£RVTsrRia,,�..,f: �Sz"�,lV'� ����-��'u���r-D _Ei�yR'IAOil'M i�T4Z BEAlirA2t BldgApp_2011.doo revised 06i21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION JAFADDRESS: 10971 N WOLFE RD DATE: 09/21/2015 REVIEWED BY: MELISSA APN: 31606051.10971 BP#: *VALUATION: $3,500 'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY USE: Commercial Building PENTAMATION PERMIT TYPE: 1TIPREfA WORK TOFU PLUS - T.I. PREP 2866 S.F. INTERIOR ONLY NON STRUCTURAL SCOPE Mech. Phm Cheek Phunb. Plan Check Alec. Nan Check Rdecla. Permu bee: Phrmb. Perlire: L1eC. Itv'r)nit Fee: Other Alech. hasp. Other Plumb Imp. Other Alec. lnst>. 137 Meeh. Imp. Fen, Plumb. Imp. Fee: Alec. Insp. Fee, NOTE: This estimate does not include fees Clue to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the preliminary information available and are onlv an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Rcsolution 11-053 Eff 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # $417.00 Tenant Improvement Prep ITIPREP • Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Administrative Fee: 0 Work Without Permit? ® Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 • 0 Travel Docurnemation Fees: Strong Motion Fee: IBSEISMICO $0.98 Select an Administrative Item Bide Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $1.98 $417.001 TOTAL FEE: $418.98 Revised: 07/02/2015