10080200 CITY OF CUPERTINO BIUILDING PERMIT
BUILDING ADDRESS: 20755 STEVENS CREEK BLVD CON—RACTOR:BALCH PERMIT NO: 10080200
PET]tOLEUM INC
-'WNER'S NAME: CONOCO PHILLIPS PO FOX 361230 DATE ISSUED:08/27/2010
OWNER'S PHONE: 8059079330 MIL'ITAS,CA 95035 PHONE NO:(408)942-8686
❑ LICENSED CONTRACTOR'S DECLARATION
�J' t BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class A a c 7JJ V�ic.# Ti v S r
� Q� MECH RESIDENTIAL COMMERCIAL
Contractor RDate � 0
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ISD UPGRADES AT SERVICE/GAS STATION ALL LOW
VOLT AGE SENSOR COMMUNICATION
(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:
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. Sq.FFloor Area: Valuation:$7500
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 APN Sumber:32632056.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the l J
granting of this permit. Additionally,the applicant understands and will comply Issued by: �/�6- Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
GZ rQ ROOFS:
•natur Date D All ro ifs shall be inspected prior to anyy roofing material being installed.If a roof is
instal ed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I hav:read the hazardous materials requirements under Chapter 6.95 of the
Califrrnia Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three main:ain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Heap h&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's mate•ial. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air cc ntaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will in compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the II ealth&Safety Code,Section O5,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this �� Z
Owner or authorized agent;/ Date:
permit is issued. U
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I here by affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work'3 for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
building construction,and hereby authorize representatives of this city to enter
,n the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I and.rstand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licer sed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR—BU11LDING DIVISION
Is ADDRESS: 20755 St. Creek Blvd DATE: 08/27/2010 REVIEWED BY: jsg
APN: BP#: *VALUATION: 1$7,500
*PERMIT TYPE: Electrical Permit PLAN CHLCK TYPE: Alteration /Addition / Repair
PRIMARY 707,21, PENTAMATION 1 CEAP7
USE: Commercial Building VI,OOR 41�t A, I PERMIT TYPE:
WORK ISD U grades at Service/Gas Station. All low voltage sensor communication.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES
Apparatus 1BREMMISC 1 $126
TOTALS: $126.00
,/I I'Ca",Ch"(A Plna;h. Phi"i"t-'tx'cd. Elec.Plan Check 0.0 1 hrs $0.00
,,a Fc'r: 11'himh, 11(-, Fce, Elec.Permit Fee: IEPERMIT
c?nc�'r afecft. trF�,� F-1 I orh�>> Phjo,t7 Iri",� Other Elea Insp. 0.0 hrs $42.00
1,1"f h Mn P, Phrar,l, iuw. I'C", My, /",("
NOTE: Thesefees are based on the preliminary information availabje and are only an estimate. Contact the De t or addh7 info,
FEE ITEMS {Fee Resolution 09-051 E f 7/1110) FEE QTY/FEE MISC ITEMS
1'km Clrc'c'h Fc,':
Sid,)/>l M ,Fcc F-1
PME Plan Check: $0.00
l c't717i7 1"c'E''
Std/)/)/, hop I cv
PME Unit Fee: $126.00
PME Permit Fee: $42.00
('uJ1NWIICIII 7 1�n
[tv.
Work Without Permit? ® Yes (E) No $0.00
Travel Documentation Fee: ITRAVDOC $42.00
,SIron,i tlorifm Select an Administrative Item
Bldy,Stds Commission Fee: IBCBSC $1.00
:SUBTOTALS: $211.00 $0.00 TOTAL.FEE: $211.00
Revised: 8/17/2010
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32632056 . 00
DATE ISSUED. . . . . . . : 08/27/2010
RECEIPT #. . . . . . . . . : BS000011311
REFERENCE ID # . . . : 10080200
SITE ADDRESS . . . . . : 20755 STEVENS CREEK BLVD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CONOCO PHILLIPS
ADDRESS . . . . . . . . . . : 6020 W OAKS BLVD #200
CITY/STATE/ZIP . . . : ROCKLIN, CA 95765
RECEIVED FROM . . . . : BALCH PETROLEUM
CONTRACTOR . . . . . . . : BALCH PETROLEUM INC LIC # 22542
COMPANY . . . . . . . . . . : BALCH PETROLEUM INC
ADDRESS . . . . . . . . . . : PO BOX 361230
CITY/STATE/ZIP . . . : MILPITAS, CA 95035
TELEPHONE . . . . . . . . : (408) 942-8686
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 7, 500 .00 1 . 00 0 . 00 1 . 00 0 .00
1BREMMISC EACH 1 .00 126 . 00 0 . 00 126 . 00 0 .00
1EPERMITFE FLAT RATE 1 .00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 .00 42 . 00 0 .00 42 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 211 . 00 0 .00 211 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 211 . 00 75280
---------------
TOTAL RECEIPT 211 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
CITY OF CUPERTINO
CUPEKTINO GENERAL BUILDING
PERMIT APPLIC.�.TION FORM
/Ownd�
APN# OU
Date: < z2to 7
Building Address: 7C>75-15-
Mailing
d7S15-Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: (Exterior work only) Yes ❑ No ❑ If yes, :-ovide letter from HOA
Owner's Name:cc)✓10 Lc,�, Phone#:<;C G s, 01677-
,330
Contractor: \ Phone: -" - `j Z- kG,?sp
Fax: AM e\
Contractor License
Cupertino Business License#:
Contact: F)ooj Z-,Iep— F-� Phone: c�oV 011'2— 25'C.*6
— Fax: 05� —a1S
Residential Commercial
Job Description: �S� U f
INA
Building Permit Info:
Bldg ❑ Elect 1z Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/UI/V-A ❑ II/VI B, IV-HT, V-B ❑ _
Valuation: b Square Footage:
Project Size: Express ❑ Standard ❑ Large ❑ 1vfajor ❑
Green Building: Please complete relevant portion of the Green Buulding/LEED Checklist & attach it
to the application or if applicable, inclu de in plan set& the sheet index.
oints Achieved:
For help, contact Build it Green at www.builditgreen.or�
Revised 07/14/09