11090140CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: I RESULTS WAY I CONTRACTOR: XL CONSTRUCTION I PERMIT NO: 11090140
OWNER'S NAME: EMBARCADERO CAPITAL PARTNERS 1851 BUCKEYE CT
DATE ISSUED: 09/20/2011
ER'S PHONE: 4089961010 I MILPITAS, CA 95035 I PHONE NO: (408) 240-6000
LICENSED CONTRACTOR'S DECLARATION
j/
License Class Lic. # (0"( O
Contractor
1 hereby affirm that I am licensed under the provisions o Cha er 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 have and will maintain a certificate of consent to self -insure for Worker's K)
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 harmle the City of Cupertino against liabilities, judgments,
costs, and expenses whic ay accrue ainst said City in consequence of the
granting of this pe t. ditionally applicant understands and will comply
with all non -poi s u regulation r the Cupertino Municipal Code, Section
9.18.
L OWNER -BU ER DECLARATION
1 hereby a rm 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,
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).
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 pennnit shall be deemed revoked.
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,
C, and expenses which may accrue against said City in consequence of the
L. g of this permit. Additionally, the applicant understands and will comply
wiu, all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
BUILDING PERMIT INFO: BLDG I— ELECT r— PLUMB`
MECH F RESIDENTIAL f- COMMERCIAL
JOB DESCRIPTION: APPLE -BLDG 12 - DEMO/PREP- COMMERICAL, OFFICE_.
SPACE
INTERIOR ONLY
Sq. Ft Floor Area: I Valuation: $50000
APN Number: 35720041.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued b- Date: - 2
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
1 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 a defined bye Bay Area Air Quality Management District I will
maintain co ance with The CgIfertino Municipal Code, Chapter 9.12 and the
Health & y Cod;So,ions 505, 25533, and 25534.
Owne
C
I hereby affirm tha(lt re is a construction lending agency for the performance of work's
for which this perriV is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date I Licensed Professiona
CITY OF CUPERTINO
FM_7 FEE ESTIMATOR - BUILDING DIVISION
ialADDRESS:
1lresults way bldg 12
DATE: 09/20/2011
REVIEWED BY: bobs.
.
tr r i P r)w., I., -
APN:
BP#: _....... --
"VALUATION: 1$50,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY Commercial Building
USE:
i ..
PENTAMATION 1TIPREP
PERMIT TYPE:
WORK
demo/ re commercial offices ace interior only.
SCOPE
PME Plan Check:
NOTE: This estimate does not include fees due to other Depts (ba Public Works, 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 Resolution 11-053 E . 7/1/11)
FEE
QTY/FEE
Etre. i'wli Ci,i cf
.
tr r i P r)w., I., -
__.
Li
0 #
$380.00
Tenant Improvement Prep
ITIPREP
i ..
Suppl. PC Fee: (F) Reg. 0=0T]
NOTE: This estimate does not include fees due to other Depts (ba Public Works, 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 Resolution 11-053 E . 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
0 #
$380.00
Tenant Improvement Prep
ITIPREP
Suppl. PC Fee: (F) Reg. 0=0T]
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Feer Reg.
0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
s. 'tF�a.rlr•rt: •ri c1t1 7� r.t
£clnr:ni: tr tti+ : l E
Q
0
Work Without Permit? Q Yes No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
Q
0
Strong. Motion Fee.
IBSEISMICO
$10.50
Select an Administrative Item
Bldg Stds Commission Fee: iBCBSC
$2.00
SUBTOTALS:
$12.50
$380.00
TOTAL FEE:
$392.50
Revised: 09/02/2011