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10120143CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10617 S DE ANZA BLVD CONTRACTOR: PROVISION PERMIT NO: 10120143 DEVELOPMENT, INC. OWNER'S 'S DECLARATION r r r Class P-,.? 25319 BUILDING PERMIT INFO: BLDG ELECT PLUMB License Lic. #_ MECH r RESIDENTIAL r COMMERCIAL r Contractor Y I S I u f4 6—VIDate I `?A I hereby afArn that I am licensed under the provisions of hapter 9 JOB DESCRIPTION: SUITE B, 50 SF, ALTER EXISTING BUILDING WITH NEW (commencing with Section 7000) of Division 3 of the Business & Professions T-BAR CEILING, NEW LIGHTING, ADD ONE ADA RESTROOM, Code and that my license is in full force and effect. MODIFY DIFFUSERS, REPLACE ONE WINDOW W/NEW I hereby affirm under penalty of perjury one of the following two declarations: 1 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 Sq. Ft Floor Area: Valuation: $25000 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 35918044.10617 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above informal on 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 ' ' PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino agains ies, judgments, costs, and expenses which may accrue against sa' onsequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, th lc derstands and will comply ' 180 DAYS FROM LAST CALLED INSPECTION. with all non -point 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 1, 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 (Sec.7044, Business & Professions Code) Signature of Applicant: Date: 1, 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: I have and will maintain a Certificate of Consent to self -insure for Worker's HAZARDOUS MATERIALS DISCLOSURE 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. 1 will maintain 1 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 1 will I certify that in the performance of the work for which this permit is issued, I shall maintain compliance with the Cupertin rpal 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, Sec ' Fs3 5533, 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 Owoer or' o with such provisions or this permit shall be deemed revoked. Date : C, 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. Signature Date Licensed Professional CITY OF CUPERTINO BUILDING PERMIT,ATC BUILDING ADDRESS: 10617 S DE ANZA BLVD I CONTR C OR: PROVISION I PERMIT NO: 10120143 OWNER'S NAME: 1 SUNNYVALE, CA 94086 1 PHONE NO: (408) 245-0991 1 ❑ LICENSED CONTRACTOR'S DECLARATION License Classr� Lic. # O �b 3 / Contractor f% �✓ ate I hereby a rrm 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. 1 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. 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 s ' consequence of the granting of Code, Section 9.18. ­2/ ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, wil I 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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. 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 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 I certify that I have read this application and state that the above inform ion 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, BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: SUITE B, 50 SF, ALTER EXISTING BUILDING WITH NEW T-BAR CEILING, NEW LIGHTING, ADD ONE ADA RESTROOM, MODIFY DIFFUSERS, REPLACE ONE WINDOW W/NEW 3/2/11-REV#1-RELOCATE TOILET FROM ORIGINAL PLAN- 3/2/1 I-REV#I ISSD OVR COUNTER Sq. Ft Floor Area: Valuation: $25000 APN Number: 35918044.10617 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: 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 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Ai Quality Management District I will maintain compliance with the Cu unicipal Code, Chapter 9.12 and the Date: CONSTRUCTION LENDING AGENCY 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 Address ARCHITECT'S DECLARATION Signature. Date I understand my plans shall be used as public records. Licensed Professional REVISION # 4 CITY OF CUPERTINO BUILDING PERMIT DATE s _'5' 46 ' I I BUILDING ADDRESS: 10617 S DE ANZA BLVD CONTRACTOR: PROVISION PERMIT NO: 10120143 t DEVELOPMENT, INC. OWNER'S NAME: SUNNYVALE, CA 94086 PHONE NO: (408) 245-0"1 LICENSED CONTRACTOR'S DECLARATION r F r ( BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class_ Lic. # o I— f— j" _ MECH RRESIDENTIALCOMMERCIAL 1,� �dAC Contractor Date 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 orthe 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. 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 al I 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. Signature ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). l hereby affirm under penalty of perjury one of the following three 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. 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. 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 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 l 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. JOB DESCRIPTION: SUITE B, 50 SF, ALTER EXISTING BUILDING WITH NEW T-BAR CEILING, NEW LIGHTING, ADD ONE ADA RESTROOM, MODIFY DIFFUSERS, REPLACE ONE WINDOW W/NEW 3/28/11- REV#2 - MODIFY EXISITNG DOORS & ADA RAMP-3/28/11 REV#2 ISSD Sq. Ft Floor Area: Valuation: $25000 APN Number: 35918044.10617 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 S OF PERMIT ISSUANCE OR 180 DAYS LAST CALLED INSPECTION. Issued by: CJ� Date: RE -ROOFS: All roofs shall be inspected prior to any roofing material bei7g installed. If a roof is installed without first obtaining an inspection, I agree to remove al I new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(s) should I store or handle hazardous material. Additionally, should I use 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. : CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of Hork's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Signature Date I Licensed Professional CITY OF CUPERTINO rm-M FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10615 S De anza DATE: 03/28/2011 REVIEWED BY: gs APN: BP#: "VALUATION: 1$2,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE. PENTAMATION 1BTI PERMIT TYPE: WORK Ramo and door up grade SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,III-B,IV,V-B 0 $0.00 $0.00 TOTALS: 0 $0.00 $0.00 MECH, HOURLY 0 Yes G No PLUMB, HOURLY 0 Yes Q No ELEC, HOURLY 0 Yes QNo NOTE: These fees are hated an the nreliminary infarmatinn availahle and are anly an ov imato_ Can/art the Dent far addn'1 infn_ FEE ITEMS (Tee Resolution 09-051 Eff 711110) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes (E) No $0.00 0 hours Plan Check, Hourly $126.00 ISTPLNCK Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.e Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes E) No $0.00 0 0 Work Without Permit? 0 Yes 0 No $0.00 Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 Strong Motion Fee: IBSEISMICO O. 5,V Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1 0 SUBTOTALS: 5 $ 26.00 TOTAL FEE: $127.50 r �`� Revised:01/15/2011 FM-7 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 10615 s de anza blvd. suite b DATE: 12/20/2010 REVIEWED BY: bob APN: / j' 7 L/ BP#: I Cj pi 4 *VALUATION: $25,0 *PERMIT TYPE: Building Permit IPLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: ii. 1I:OUR,4h[ i. PENTAMATION 1B TI PERMIT TYPE: WORK SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.E PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,III-B,Iv,v-B 50 $1,856.00 IBTIPLNCK $520.00 IBTIINSP TOTALS: 50 $1,856.00 $520.00 MECH, HO O Yes O No PLUMB, HOURLY Q Yes Q No ELEC, HOURLY Q Yes Q No alc'ctl. Plan, C'40.4 i Lrllrh. Plun C :4cc1 b/c'r. Pion ( f,,. �: 1.rr , !'i>,`77u �--: �,:-• FIT, i'lrr�rih, Pc; nsil Fee. Flc'(.. /'�_, rA/,,h. 0dj' �rPh4MhM"q). OiNe, i.s: � . la=ti{�. IMSJ). l.t.n. 1'ryl7•'i ). %I1sp. Fee: Flec'. h;)!). /', NOTE. These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addh 7 info. FEE ITEMS (Fee Resolution 09-051 E . 7/l/l0) FEE QTY/FEE MISC ITEMS Plan Check Fee: $1,856.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $520.00 Suppl. Insp. Fee-.0 Reg. © OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction .Ta Acoustical Fee: 0 Yes 0 No $0.00 0 E) Work Without Permit? 0 Yes E) No $0.00 PlanninS Fee: PLLONGRNGC $0.00 E) 0 I Travel Documentation Fees: Strong Motion Fee: IBSEISAfICo $5.25 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $2,382.25 $0.00 TOTAL FEE: 1 $2,382.25 Revised: 12/07/2010