B-2017-1486 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1486
11111 N WOLFE RD CUPERTINO,CA 95014-0601(316 05 072) SECURITY VAULT
WORKS INC
LAUREL,MD 20707
OWNER'S NAME: CUPERTINO VILLAGE LP DATE ISSUED:09/11/2017
OWNER'S PHONE:650-746-7502PHONE NO:(301)776-2577
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LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#904878
Contractor SECURITY VAULT WORKS INC Date 10/31/2017 X BLDG _ELECT _PLUMB
MECH_RESIDENTIAL X COMMERCIAL
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. JOB DESCRIPTION:
BANK OF THE WEST-REPLACE ATM;RE-STRIP HANDICAP
I hereby affirm under penalty of perjury one of the following two declarations: PARKING;FIX ADA RAMP;ADD DEDICATED CIRCUIT
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.
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. Sq.Ft Floor Area: Valuation:$15000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 05 072 A(Tenant Improvements)
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City,in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cu -rtino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
s`,mom Date 9/11/2017 Issued by:Jasmine Archbold
' Date:09/11/2017
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS;
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will dothe work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:9/11/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25550055 25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Own; cm thorized agent: i� ''�
APPLICANT CERTIFICATION !a' r'ir 21 7 /"
I certify that I have read this application and state that the above information is CONST UCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply,with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Cbde,Section 9.18. , I understand my plans shall be used as public records.
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Signature Date 9/11/2017 Licensed
Si
9 Professional
CONSTRUCTION PERMIT APPLICATION
\/•�i_,_ COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIONB ,
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
01.,p„.... (408)777-3228 • building@cupertino.org PEMIT#B- 20 I -
CUPERTINO REV# DEF#
0 NEW CONSTRUCTION ❑ADDITION 0 ALTERATION T.I. 0 MEP ❑RE-ROOF 0 SWIMMING POOL/SPA
PROJECT ADDRESS Ic�Vt4 APN# y�
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STREET ADDRESS EZIP
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TYPE
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❑ARCHITECT 0 OWNER ❑OWNER AGENT 0 CONTRACTOR AGENT❑.ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME E-MAIL i V,�OL� Svu-,\._e
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❑SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY ❑INDUSTRIAL 0 COMMERCIAL, I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($) ,
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING
0 EICHLER ❑YES SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS 0 NO 0 NO 0 NO
DWELLING SECOND DWELLING DYES 0 ATTACHED 0 DETACHED OTHER
imrs# UNIT ADDITON: ❑NO S F
POOLS' 0 FIBERGLASS 0 VINYL-LINED ❑GUNITE ❑PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED ❑YES .: NO I TOTAL-SF r'
IVEDBY: �I / a'u: m Qa�_
Co me,cial Dr Multi-Family Buildings with Public Sulu:nu a Pools moires Department ofEnvirotm Environmental Heath anoroval 1, r y+ p .;,' i ,% ,,,P-o. '" 4.
RE-ROOFI EXISTING ROOF TYPE: ❑BUILT-UP ROOF 0 ASPHALT SHINGLES 0 WOOD SHAKES p WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD El ❑3/B" PLYWOOD TYPE: PITCH:
' DYE,I#OF LAYERS THICKNESS D 5/8" OTHER ❑OSB ❑CDX OTHER :12
ROOF ACLASS
I PROPOSED.ROOF TYPE:❑BUILT=UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES OWOOD SHINGLES 0 OTHER
*Provide a signed copy of the,Cupertino's Tear-Off Policy SF Sof SQUARES
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 correct. I 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 building construction. I authorize representatives of Cupertino to
enter the above-identified property for' on,urposes. I acknowledge and authorize all information nta'led on this application form,
to be made available for public recon���
Signature of Applicant/Agent: �4;,_ Date:
SUPPLEMENTAL INFORMATION REQUIRED '
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction. ,
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous 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. ,
*HOA-Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17 •