11020033 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20450 STEVENS CREEK BLVD STE 250 CONTRACTOR:GIDEL AND KOCAL PERMIT NO:11020033
OWNER'S NAME: CUPERTINO CITY CENTER 574 DIVISION ST DATE ISSUED:02/28/2011
OWNER'S PHONE: 4088730121 CAMPBELL,CA 95008 PHONE NO:(408)370-0287
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❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class /_3 Lic.# 4v3®570 W
MECH RESIDENTIAL COMMERCIAL
Contractor Cay 'EKG. Date
I hereby affirm that I am licensed under the provisiois of Qfapter 9 JOB DESCRIPTION: STE 250-COMM'L TENANT IMPROVEMENT-51 SQ-
(commencing with Section 7000)of Division 3 of the Business&Professions REMOVE
Code and that my license is in full force and effect. COMMON HALLWAY DOOR&FILL IT IN.BUILD TWO(2)
WALLS ON BREAKROOM TO ENLARGE.ADD ONE(1)DOOR TO
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.
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:$25000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:36901028.250 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
9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by: Date:
❑ 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 being 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,I 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)
I,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 I 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. Owner or ayflWized agent:
Date:/
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 relati g 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.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
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CITY OF
CITY OF CUPERTINO
TENANT IMPROVEMENT
C U P E RTI N O PERMIT APPLICATION FORM
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Date:
2/) 0 1 0 D
Building Address:
C)/
Mailing Address (if different from building address):
Tenant ❑ (If tenant please provide a letter from the building owner approving the tenant improvement.)
Building Owner
Are Hazardous Materials being used as part of this project? Yes ❑ No
Tenant/Building Owner's Name: Phone#: e 75- o/2�(
(ZopiteTwe) 17* C✓ T
Contractor: Phone#: 08 _
GA &SmU&oA) Fax#: 70- ,� S
Cupertino Business License: State Contractor License#:
D
Contact: Phone#: f
Fax/y.-mail: ) 3-70 ®v 3S
Landsca a Ordinance Compliance:
Landscape area in sq. ft. (includes all irrigated areas):
If 2,500 sq. ft. or less, compliance with the Landscape Water-Efficiency Checklist is required.
If more than 2,500 sq. ft., a complete Landscape Project Submittal is required.
Compliance Method: ❑ Plant Type ❑ Water Budget
Job Description(be specific): eglul (146 �-_p!telmo0 L1�iL c2� D j
-7--r /A), B0/14 7WO 610s
eye �� �D ®� � 70
Tenant Improvement Includes Re-Roof: Yes ❑ Nog If yes, number of squares
Tenant Improvement Includes Structural Yes ❑ No [�
Type of Construction(Usage Class): Occupancy Type: c5
1-A, I-B ® IIJIII/V-A ❑ II/III B, IV-HT, V-B ❑ Valuations: 2S/ coo
Project Size: Counter ❑ Express ❑ Standard ® Large ❑ Major ❑
Green Building: Please complete Leed for commercial interiors checklist & attach it to the application
or if applicable, include in plans & sheet index
LEED Points Achieved �_
*** For Office Use Only*** Revised 12-06-10
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CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS. 20450 stvns crk blvd. DATE: 02/08/2011 REVIEWED BY: bobs.
APN: BP#: *VALUATION: $25,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY PENTAMATION 1 GENCOM
USE: Commercial Building PERMIT TYPE:
WORK t.i. commercial offices ace includes plumbing, electrical non structural
SCOPE
jl'(cch. Plan c hf:ck
Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check Hhrs $0.00Permit Fee: Plumb.Permit Fee: IPPERMIT Elec.Other Afec•h. hasp. Li Other Plumb Insp. 0.0 hrs $42.00 Other Elea Insp.
11-Icc7�.IusEz Fee:
Yhnnb. fnsp. Pee: Glee.Insp.Fee:
NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS (Fee Resolution 09-051 ff. 7/1/10) FEE QTY/FEE
MISC ITEMS
Plan Check Fee: $0.00 51 1.£ Interior Partitions
Suppl.PC Fee: (j) Reg. 0 OT 0.0 hrs $0.00 $538.00 IPARTICOMM
PME Plan Check:
$0.00 ® Electrical
Permit Fee: $0.00 $63.00 IBREMFIXT Fixtures,Lighting
Suppl.Insp.Fee-0 Reg.
0 OT 0.0 hrs $0.00 �� # Plumbing
PME Unit Fee: $0.00 $16.00 IBPFIXTURE Fixture or Trap
PME Permit Fee: $84.00
Cgrrslructiorr Tox E1__
Acoustical Fee: ® Yes (D No $0.00
Work Without Permit? 0 Yes G No $0.00
Planning Fee: $0.00 Select a Non-Residential G
Building or Structure 0
Travel Documentation Fee: ITRAVDOC $42.00
Strong Motion Fee: IBSEISMICO $5.25 Select an Administrative Item
Bld�mmission Fee: IBCBSC $1.00
SUBTOTALS: $132.25 $617.00 TOTAL FEE: 1 $749.25
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Revised: 01/15/2011
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