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12050062 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR CONTRACTOR:THE FORUM RANCHO PERMIT NO:1205OQ62 SAN ANTONIO OWNER'S NAME: THE FORUM RANCHO SAN ANTONIO 23500 CRISTO REY DR DATE ISSUED:12/03/2012 OWNER'S PHONE: 6509440167 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIALE] rise Class Lie.# COMMUNITY BLDG-CONSTRUCTION OF A 812 SQFT Lice STORAGE BUILDING,CONSTRUCTION A 318 SQFT PORTE Contractor t 1 c U Date COCHERE I hereby affirm that I am licensed under the provisions of Chapter 9 - (commencing with Section 7000)of Division 3 of the Business&Professions REV#1 ADD LIGHT POLE TO(E)DRAWINGS— Code and that my license is in full force and.effect. APPROVED OVER-THE-COUNTER 2/28/2013 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. Sq.Ft Floor Area: Valuation:$250000 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 APN Number:34254999.00 Occupancy Type: 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-gF 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 FRP LA T_C�ALLED 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 4srsued by: Date: granting of this permit. Additionally,the applicant understands and will compjy-' with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. m - RE-ROOFS: Signature ` Date t 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: I hereby 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). I have read the hazardous materials requirements under Chapter-6M 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 Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533, nd25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: L 0e: 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 CONSTRUCTION LENDING AGENCY' 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 I hereby affirm that there is a cbnsl lendmg 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. "i } Lender's Name . ­­owl 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 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 23500 CRISTO REY DR DATE: 02/28/2013 REVIEWED BY: MELISSA APN: 342 54 999 BP#: 'VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY PENTAMATION USE: Commercial Building PERMIT TYPE: 1GENC0 WORK REV# 1 -ADD LIGHT POLE FOOTING TOE DRAWINGS FOR PERMIT FOR DETACHED SCOPE STORAGE _tech.}elms Check Plw;,h. Plan Check Elec..Plan Check 1 tech. ptt nr lit Fee: Plursin.Permit Pee: Gtec.Derr it Pee: 0117ef•llech.Insp. other Plumb hssp. orl;er Glee.Insp. illech.Insp.Fee Plumb. hrsp.Fec, Elec.Imp,Fee: NOTE:This estimate doeswot include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These&es are based on the prelinddna information available and are only an estimate- Contact the Dept-for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? )Yes ) No $0.00 0 hours Plan Check,Hourly Suppl.PC Fee: ) Reg. ® OT 0.0 hrs $0.00 $266.00 1S7PLNCK PME Plan Check: $0.00 Permit Fee: $0.00 Suppl.Insp.Fee:.) Reg. ) OT0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 const7-LxTion Tax:. _2 If�ia�iszs crt l�e Fee: Work Without Permit? ) Yes No $0.00 ) Advanced Planning Fee: $0.00 Select a Non-Residential Building or Structure ) T-6,vec DocumentaiIo r Fees: Strom Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $266.00 TOTAL FEE: $266.00 Revised: 01/0112013 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR CONTRACTOR:THE FORUM RANCHO SAN PERMIT NO:12050062 ANTONIO OWNER' NAME: THE FORUM RANCHO SAN ANTONIO 23500 CRISTO REY DR DATE ISSUED:12/03/2012 OWNER'S PH NE: 6509440167 CUPERTINO,CA 95014 PHONE NO: LI NSED CONTRACTOR'S DECLARATION ' BUILDING PERMIT INFO: BLDG' ELECT PLUMS License Class Lie.# MECH"r— RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am lic sed under the provision of Chapter 9 JOB DESCRIPTION:COMMUNITY BLDG-CONSTRUCTION OF A 812 SQFT (commencing with Section 70 of Division 3 of the usiness&Professions STORAGE BUILDING,CONSTRUCTION A 318 SQFT PORTE COCHERE Code and that my license is in f force and effect. I hereby affirm under penalty of per' ry one of a following two declarations: I have and will maintain a certificate of c sent self-insure for Worker's Compensation,as provided for by Section 3 of the Labor Code,for the performance of the work for which this pe t' issued. I have and will maintain Worker's Compe cation surance,as provided for by Section 3700 of the Labor Code,for the erformanc of the work for which this Sq.Ft Floor Area: Valuation:$250000 permit is issued. APPLIC T CERTIFICATIO APN Number:34254999.00 Occupancy Type: I certify that I have read this appli6ation and state that the ab ve information is correct.I agree to comply with 1 city and county ordinances d state laws relating to building construction,and ereby authorize representatives o s city to enter upon the above mentioned roperty for inspection purposes. (We ee to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnifyand keep h ess the City of Cupertino against liabilitie judgments, costs,and expenses w 'ch may accrue against said City in consequen of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this pe t. Additionally,the applicant understands and wi comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-po' source regulations per the Cupertino Municipal Code, ction 9.18. Issued by: '`1`" Date: Signature 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(Scc.7044, Business&Professions Code) Signature of Applicant: Date: I,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 Ow�ie"r or aut or genu" F � � � .h �� �.F�•,_ forthwith comply with such provisions or this permit shall be deemed revoked. `` ' Date: 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 costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. 1 � �A'�/ Signature t " Dater 2 Licensed Professional �, CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 23500 Cristo Rey Drive DATE: 05/08/2012 REVIEWED BY: A. Salvador tA PN: BP#:: ��Q �— "VALUATION: $250,000 ;'PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY Civil/Religious activities PENTAMATION USE: Commercial Building inBQzone? 0 Yes 1S1 Q No PERMIT TYPE: WORK New Storage Building 812 S.F. • New Porte Cochere 318 S.F. SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. S-1 (Moderate-Hazard) II.B,III-B,IV,V-B 812 $5,867.05 1SIPLNCK $1,141.41 ISIINSP TOTALS: 812 $0.00 $1,141.41 L1 I NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS(Fee Resolution 11-053 E . 7f /1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? Q Yes 0 No $0.00 © hours Plan Check,Hourly Suppl. PC Fee: D Reg. Q OT0.0 hrs $0.00 $780.00 ISTPLNCx PME Plan Check: $0.001= # Covered Porch Permit Fee: $1,141.41 $914.00 1 COVPORCx Suppl. Insp. Fee-.(F) Reg. Q OT 0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: 1BCoNsTaxc $2,062.48 Work Without Permit? © Yes (F) No $0.00 0 Advanced Planning Fee: PLLONGRNGC $211.12 Select a Non-Residential Building or Structure Strong Motion Fee: IBSEISMICO $52.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $10.00 SUBTOTALS: 1 $3,477.511$1,694.00 TOTAL FEE: F $5,171.51 Revised: 04/01/2012