13050083 .CITY OF,CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 105007NDE ANZA BLVD CONT"C-TOR;DEVCON PERMIT NOr 13050083
CONSTRUC-TION IN_C
•OWNER'S'NAME: MISSION WEST'PROPERTIES LP IV ;696,GIBRALTAR-DR `DATE ISSUED:05/09/2013'
OWNER',S SHONE:.4088629,794 :MILPIT•AS';CA:95035 'PHONCINO:(408)942=8200
� LIC
-- .EN.SED:CONTRACTOR'S DECL:A- -R:ATION JOB DESCOP„„TION: RESIDENTIAL El COMMERCIALE]
_
LicenscCdass Lic,# APPLE-COM -T.1 4TH.FLO:OW 1,744 S"Q_FT_ TO INCLUDE
/'�� NEW`-OFFICE,AND CONFERENCE ROOM
Contractor, 3&O/E, ` Date,
ere, in that;I am'licensed finder the:peovisi sto " hapter ;9
(commencing with Sectiorr7000),of,Division;3 of the Business&c-Professions
Code;and;thatmy license-is„in full foree;and effect.
I hereby affirm:under penaltyof perjury one of:the following'two declarations:
I,tiavei.and will maintain a certificate of consent to self-insurcrfor'Workcr's
Compensation,aas provided for.by Section 3700 ofthe Labor.Codcjor'the.
,perfoimance0thc�work forwhich this perinit,is issued. S4.Ft Floor Area:; V„aluatioq:,$I50000
have and will,maintain.Worker's Coriipensation Insurance,as provided for by
Section 3700:of the'Labor Code;for the performancc:'of the work for which4lhis
- permifis�issued.
AVN Number:,31622017.00 Occupancy Type:
APPLICANT`CERTIFICATION
1"6ertify that;l have read this applicatiomand state thafthe above inforniatibwis` PERMIT EXPIRES IF WORK IS
NOT-STARTED
correct-1 agree to.compl'y With;all,city and county(?dmancesrand`state lawstrelating WITHIN 180,D'AXS OF PERMIT"ISSUANCE OR
to budding construction„and hereby authorize representatives of,t8is,city to enter
p.rP
._,. - p p p )agree � =M LAST CALLED INSP CTION.
u onthe;above:'menponed;"ro ert”"fy�ins epctiom ug oses:.:We a �e g save 180 DAYS- "
P Y
indemnify'and keep)harrWss the.Cit °of Cupertino a amst liabilities, ud ments;
costs.1and.expenseswhich may"accrue�against said City in,:consequence of'the
granhng,,of this;permit. Additionally,the appli. ant=undctstands!,and will comply Issued'by: Da"te [
' with all nonpoint'source;regulations perthe. upertino Municipal Code;Section
RE-ROOFS:
Signature \ Date All roofs shall be inspected;priorto any roofing:material beinginstalled:e-a.roof is
installed Without hist obtain_in anlinspection,I agree tgremove all new materials:for
inspection.
❑ OWNER-.BUILDER DECLARATION
Signature,ofApplicantt Date:,
`I"hereby affirm.thailLam exempt from the Contractor's License Law for one of
„r.
p Y p. Y ALL,ROOF'CO`JERINGS TO BE,CLASS"A"OR BETTER
th'e,following two'reasons:
I;;as oWnerof the, ro e. ;,or m em to ees with wages as their;sole compensation,
will do the work;,and'the structureis;not intended_ ondfMied`.forrsale(Sec:70,44, _
'Busi`ness&ProfessionsCode)
1,1,as;ownerrofthe,property,am exclusively contractiiig with licensed contractors:to,
HAZARDOUS MATERIALS,DISCLOSURE
construct'thi roect Sec.7044,Business&-Professions Code: -
p J, ( ) I•have read thChazardous materials requirements under Cha the
California Health&Safety Code;Sections 25505'25533,and.25534; I will
I,heretiy9affirm under penalty of,perjury'one,of Elie followrng;tFiree. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and`the
rdeclarations: Health&sSafety,,Code,Sec'ti'on 25532(a)�should;I store or handle hazardous
[have and will+rl5aintaimia.Certificate of ConsentAo;self=insure for Worker's. material. Addiiionally,,should,I use equipment or deviceswhieh_,emit,hazardous
Compensation,as provided for by'Section 3700:of the Labor Code;for the airIconiam_inantsas define&& the Bay-Area Air Quality Management"Districf I
performance of theWork:for which this„permit,is;issued. will maintaincompliance with the,Cupertino Municipal Cod e;-Chapier 1 12 and.
&.Safe Health ”
I;have-and will mainWor
tain` ker�s�Cornpensafion Insurance,aspro`vided,"for'by the- ty Code,See.tions25505,25533,and.25534.
Section 3700 of the:LaborCode,;forithe;performance,ofthe,work for which this 4
Owneraor authorized agent: , Date:
permit,is issued:,
I�certify that in-ihc;performance;of the>Woik:for,which this permit is issued,lwshall,
not emptoy any perso.Win any manne.r..so alto become subject fo the Worker's
'Comp-ensationlaws;ofCalifornia. If,'after,making this certificate ofezemption,I. CONSTRUCTION LENDING AGENCY
become subject to the Worker'sCom'p_ensationprovisionsof fic Labor Code,;l must, 1 hereliy'afficm thavthere_is aFconstruction lending_agency'for the performance:of
forth*i&coinply`wiih,such provisions or tfiis permit shalf be,deemed:revoked. work's for which this permit is issued.(Sec.-3097,Civ C.)'
Lender's°Name
APPLICANT<CERTIFICATION Lender'§Address
Lceriify that,l lia6e,read.thisiapplication and statCthatthe above information°is: ,
' correct;j agree to:comply'with4ll city and and'stateilawsrelati—,
to building?construction,and.hereby,authbrize representatives ofthis,city'to enter- „
upon the7above7mentioned"property forxrnspection purposes (We)agree to$save
lt"indemn"ify and"keep harmless theCrty.of Cupertino against liab Irties,Judgments, ARCHITECT'S DECLARATION
:.
costs,sand expenses which niary crue;againstsaid City 1 inconsequence of the I anderstand myplans,shall be used,as publiarecords.
granimg�oftfiis permit.Additionally,the:applicant-understandsland.,will comply
With all non-point'ssource,regulations penthe'.Cupertino Municipal,Code,Section Licensed':9.18. .. - -
Signature" Date
CONSTRUCTfON PERMIT APPLICATION
COMMUNITY DEVELO'PMENT'DEPARTMENT�BUILDING DIVISION b(
10300 TORRE AVENUE'o CUPERTINO', CA 95014-3255
(408)777-3228 FAX.(408)177-3333 building aa-cupertino.orq
CD NEWONSTRUCTION
Q ADDITION [eTERATION'/T[ D. `REVISION!DEFERRED ORIGINAL PfiRMIT,#
T
PROJECT ADD$ESS 1 g� APN#
OWNERNAN,M, -(� - - PHONE -
;ADDRESS CITY, STATE
/� ``. ;ZIP, FAX
STREET
ACT NAME L qs: PHONE EMAIL
ixl y
STREETADDRESS' CITY,STATE, ZIP l FAX
4.�
❑OWNER .❑ OWNER-BUILDER ❑ OWNER.A GENT' NTR.4CTOR ❑coNTRAC1.ORAGENr ❑ 'ARCHITECT ❑ENGINEER ❑ DEVEwPER ❑TENANT
CONTRACTOR,NAMEo, Let `LICENSENCiMB LICENSE TYPE BUS.LIC4
COMPANY NAMEE-MAIL FAX
`De v c o,,�' +, a�yS is p Q Co - t, C e K.
STREET„ADDRESS. ..• * .. C1TY T' ,ZI�' PHONE,
a _ 1-6t Or
9so3s' Dom• s • rag
ARCHIPECT/ENGINEERNAME o LICENSE NUMBER BUS,,LIC#
CONIPANYrNAME E-MAIL FAX
STREET ADDRESS CITY,STATE;ZIP. PHONE
DESCRIPTION OF WORK
EXISTING USE PROP,DSIP,USE, CONSTRTYPE #,STORIES
Vii.c _Pr Q -' .
USE TYPE OCC. SQ.FT.. VALUATION($),.
EVSIG NEW FLOOR DEMO 'TOTAL
AREA �.I. {rt{. AREA AREA !NET AREA .
BATHROOM _ KITCHEN OTHER. _
REMODEL-AREA - REMODEL•AREA REMODEL AREA
' -:PORCH AREA ".DECK AREA TOTAL'PECK/PORCH AREA. GAR'AGE'AREA:: DETACH .
. .. _. - ..
..' '....' ....:. ❑ATTACH
#DWELLING UNITS:; ISA'SECONMUNII ❑•YES
SECOND,STORY ❑YES - ' -
BEINGADDED? E]NO ADDITION? ❑NO
<' PRE-APPLICATION AYES IF YES;'PROVIDE COPY,oF=._ IS THE BLDG,AN ❑YES `'RECEIVED$Y 'r *. 2�t'+' "� TOTAL-VALUATION- '-
.- _ _ «,_.
FPLANNING'APPL-.# ❑T10? PLANNING'APPROVALLETTER EICHLERIiOME? ❑NO a� `"� \-"'-s �'�. ,
a Y li ation and the'informatio I have roVlden; correct. I,have,read the Descri tion of Woik,and veri It i oaccurpe. Dapree,t&c s'behal£ 1-have a read this
B m,sinature below„I certi ,weach of the followir : I'.atn the: roe owner'or autho_nzed`a'enbto acC
�� v
pp p p fy siaccurate. Iaagree totcomply-with all applicable local
ordinances andstat@°laws relating to buil_di preseniativeslof Cupertino.to_enter therabove-identi d pr 'inspection pwposes.
Signature ofApplicanOAgent: - Date: S.
MENTALJNF D
SU?PLE � kms= s t,
• .- 4P�ANCHECK�TxYPE,� :w �"*' ;4��
- On'permitifor '�mx-psi.?x� �`Is r� p k s '�” ,�
New SFD or;Multifamily PP Y for demoliti HCl zovRT�coutvTERL7BuunlNcPLAt\ EVIEs #
existing I uilding(s) Demolition permrt;isrequired;prtor.to Issuance of building
.pe`rmiffor new building. 1 EXPREss `` k ; � rLnrtrrlivG pinN vlE
u
Coffinercial.Bldgs: Provide,a completed Hazardous Mker-ials.Disclosure ksTArmnRD t �0 ruBl ictivoRxs l , , k
forri p any,.Hazaidous'Materials are being used.as}fart"of,this project:
_.,Copy of Planning Approval Letter or Meeting with'Plarining prior to . Err Dxrc
,submittal of,Buildifl Permit a licatiori7 MASOR� r��I� a e IT SEWER IST
- g PP
§'SDENyiROPIMENT
BldgApp_201.1'.doc;cevised'06/21%11.
CITY OF CUPERTINO
�° :FE'E ESTIIVIAT.OR— BUILDING DIVISION
ADDRESS--10500 N DE ANZA BLVD DATE. 05!0912013 REVIEWED BY: MENDEZ'
,APN: 'BP#: `VAL'UATION: $6,500
%PERMIT TYPE Building Permit PLAN CHE:fWfYPE:. Tenant Improvement
i'-PRIMARY PENTAMATION
Commercial Building 1GENCO M
;USE: PE]kM T'�TYPE:,
WORK 'APPLE—COMM T:I 4TH,rFLOOR- 1.-744 SQ FT TO INCLUDE NEWOFFICE AND CONFERENCE
SCOPE ,ROOM, -
:a
nal I
• Mcc7i :Plan Clieckl F,'Grfnb. 1'iUn C"lrerlr #'lcc.-fyl am(�h;eck-
Ltecfr. 1'>rir5rleia: F1 ,rrh:Pcir,l!'etrt Lcr.Pe>-mitJFee:
. C)t/rrtr:Y/ech.l'nsp: ET
1VOTE Tli'is,estimate does n'ot include fees.due;to o;her.Departmenls(ix:Planning,Poblic Works,Fire,Sanitary,Sewer District,,School
District;etcr: Thesefees are<based on tier ieliinioa, 4nformation availdb`le and are ohlylan estimate Contact'the.De t or addh!l-,in o.
FEEATEMS (Fee Resolution.1l-033 a M/12) FEE :QTY/FEE MISC ITEMS
Plan,Check:Fee: Hourly Only? 'Yes :No $0.00 2 hours Plan -heck,: H,ourly "
Suppl._,PC Fee:. Q)�Reg. OT ro,0 Hrs $0.00 $266.001STPLLNCx,
PME Plan.Check: $0.00
,Permit;Fee: Hourly Only?; Yes, No , $0.00
Suppl.`Insp.Fee.S,Reg. Q OTp p hrs $0:00'
PME:UnivFee:. $0:00
PME Pe`rmf,Fee: $0.00
Conlrzreli��n
Ar(Ilm m.stkative 1,-ee.'
Work Without Permit? 0 Yes .,E) No $0.00
Advanced Plainiii ,.t?ee $0'.00 16 Hours. Inspections
Tr ai el I�ocr"unc ntul�crn I t c s: �Inspecti h--Hourly
Stroh °IVtotion Ee'e: 1:BSEISMICO $1.37 Select an Administratiyeltein
. Bl`d�Stds�ComrnhsiomFee:o 1.BCBse' $1:0,0
--
� � SUBTOTALS $2.37 �TOTALLAFEE r .5 ^
Revised: 04/29/2013