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11090176 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10590 N TANTAU AVE CONTRACTOR:XL CONSTRUCTION PERMIT NO: 11090176 OWNER'S NAME: 10590 TANTAU INVS LLC 851 BUCKEYE CT DATE ISSUED:09/23/2011 OWNER'S PHONE: 4087264479 MILPITAS,CA 95035 PHONE NO:(408)240-6000 ❑ LICENSED CONTRACTOR'S DECLARATION r- r- I d��0 BUILDING PERMIT INFO:BLDG ELECT PLUMB r License Class Lic.# 6 //` MECH RESIDENTIAL COMMERCIAL Contractor XL_ 1��5�f w c.�e 0►'!, Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APPLE-INSTALL TEMPORARY GENERATOR FOR (commencing with Section 7000)of Division 3 of the Business&Professions EMERGENCY' Code and that my license is in full force and effect. WORK TO MAINTAIN OPERATIONS AT EXISTING DIALYSIS CENTER 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 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$30000 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:31618035.10590 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. lI' Signature Date_, Issued by:' Date: Z�~`� ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material berg installed.If a roof is I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,l agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District 1 will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. 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. Ow r authorized ent: Dater APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 1 certify that I have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional // 0� C) CONSTRUCTION PERMIT APPLICATION 12 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• building(Dcupertino.org CUPERTINO l /, ❑NEW CONSTRUCTION ❑ ADDITION /�❑ ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT# ` l 0&O "✓ PROTECT ADDRESS , V qlj n `r{1�NT,/).,O l� V`/. APN tf 1 O sf� I O� V OWNER NAME �{ ID��v� � f" L(jr� I / E-MAIL !.// STREET'ADDRESS r� ATE , FAX CONTACT NAME �� PHONE. T E-MAIL / /) STREET ADDRESS CITY,S TE ZIP 01(C FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT 11-CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER(/❑TENANT CONTRA R NAME 6 %C LICENSE NUMB / LICENSE TYPE H .LIC q 1 n�� / COMPANY NAME FAX �- Rc�z�+�i C • M' STREET ADDRESS � �^- CITY. ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS,LIC N COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING USE V PROPOSED USE CONSTR-TYPE $STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA - BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJDETACH ❑ATTACH N DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION' []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TALI, PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prpperty 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 relatin Uding construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent Date: G/ SUPPLEMENTAL TION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for C ovEx Tim cooNTlraEr sulLDnvc PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax:408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: TA.4a,, Ave-, PERMIT# OWNER'S NAME: Apple- PHONE# -ZqQ-&q3IT GENERAL CONTRACT R: XL CovIts C,+"0 V% BUSINESS LICE E# C: L ADDRESS: C ;� CITY/ZIPCODE: ,R I *Our municipal code requires h businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical GGt tl C;{ c A "C.. Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ner/4eontractor Signature Date CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10590 n.tantau ave. DATE: 09/23/2011 REVIEWED BY: bobs. APN: BP#: 'VALUATION: 1$30,000 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY Commercial Building PENTAMATION 10EAP8 USE: PERMIT TYPE: WORK install temp generator fo emergency work to maintain operations at existing dialysis center SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Generators 1 BREMPOWER 1 # $163 TOTALS: $163.00 Elec.Plan Check 4.0 1 hrs $520.00 IELCPLNC Elec.Permit Fee: IEPERMIT Other Elea Insp. 0.0 hrs $44.00 NOTE. This estimate does not include fees due to other Depts(ie. Public Works,Sanitary Sewer District,School District,etc.). Thesefees are based on the preliminary in ormadon available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (!ee Resolution 11-053 Elf 7/1/.11) FEE QTY/FEE MISC ITEMS 1'1�vl (.hock J?'c>: Siff l/. PC I,ce PME Plan Check: $520.00 PME Unit Fee: $163.00 PME Permit Fee: $44.00 -T-T Administrative Fee: IADMIN $41.00 Work Without Permit? Q Yes Q No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strom Motion Fee: 1BSEISMIC0 $6.30 Select an Administrative Item Blde Stds Commission Fee: 1BCBSC $2.00 SUBTOTALS: $820.30 $0.00 TOTAL FEE: $820.30 Revised: 09/02/2011