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15060017CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19645 STEVENS CREEK BLVD CONTRACTOR: �'g,�6tfJ p aw �4�E PERMIT NO: 15060017 A& f(wi � x,20 OWNER'S NAME: PORTAL PLAZA LP DATE ISSUED: 06/02/2015 OWNER'S PHONE: 4088575849 PHONE NO: F LICENSED CONTRACTOR'S DECLARATION ,� Nk -_� JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL REPLACEMENT OF BROKEN 4" SEWER MAIN LINE License Class '2 Lie_j jy LOCATED AT THE CLEANOUT Contractor E ; 1 1 I ate I hereby affirm that I am licensed under the pro ' ions 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 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 Sq. Ft Floor Area: Valuation: $9000 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 APN Number: 31620083 19645 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I 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 c �� C� gg �� 0 1C��4.� U1yHt/r� Issued by: YT`-{� Date: granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section RE- ROOFS: 918. _�- Y . }'� P —` Signature Dat 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. ❑ 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 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 (See.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 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & 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 material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this + .` ,j Owner or authorized agent: -- — - �% � ' Date: 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 CONSTRUCTION LENDING AGENCY 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 I hereby 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's 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 to building construction, and hereby authorize representatives of this city to enter upon 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 understand 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 Licensed Professional 9 18. Signature Date CUPERTINO GENERAL PERMIT APPLICATION 1 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(tupertino.org PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑AIISCELLANEOUS �j r ur v; Y PRO CT RESS , � I �W5 G APN - l® � U 16 o OWNERNAMq> I 6 oral PHONE _ .., E -MAIL STREET ADDRESS 'o �v21 CITY, STATE, ZIP Q, -,V, \e., FAX ca auo b(o CONTACT NAME 011...- o::b co r�-CrwAUv w oav& PHONE E -MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ o-Aq,,ER- BUIIAER ❑ OWATERAGENT ❑ CONqRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORIgAI.f LIC ER D G� i� 2Z5 ^ �1CZ TWF. 3 `(o BUS. LIC 4 . b FAX COMP TY NAME E -MAIL eh 1642 sbc STREET ADD SS CITY STATE, ZIP PHO ARCHITECT/ENGATEER NAME LICENSE NUMBER BUS. LIC tt COMPANY NAME E -MAIL FAX STREETADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY PROJECT IN WII.DLAND ❑ YES PROJECT IN ❑ YEs IS THE BLDG AN ❑ YES BUILDING: ❑ COMMERCIAL URBAN JNTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO DESCRIPTION OF �✓ % L�Ci ti! VJ 7.�' 4.z�'� (L /o' ✓J r?� '� �O /� P✓IJ�% �7Ci r TOTAL VALUATION: \ By my signature below, I certify to each of the following: I am the property owner or authorized a.ent to act on the i1foperty 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 relatingatobuil construction. I authorize representatives of Cupertino to enter the above - identified property for inspection purposes. \ding Signature of Applicant/Agent: ` -- -. Date: �— SUP EMEAIT IINTFORMATION REQUIRED OFFICE USEOI�L1 gn 1 OVER LHE CO[J�TER �. WIF gg Ong a t Plm I� ig MEPMiscApp_2011.doe revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION 21 ADDRESS: 19645 STEVENS CREEK BLVD DATE: 06/02/2015 REVIEWED BY: PAUL APN: 316 20 083 BP #: ''VALUATION: $9,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building PENTAMATION 1 CPSS USE: PERMIT TYPE: WORK REPLACEMENT OF BROKEN 4" SEWER MAIN LINE LOCATED AT THE CLEANOUT SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 hrs $0.00 QTY UNITS BP FEES Elea Permit Fee: Sewer, Sanitary 1PCSEWER Other Elec. Insp. 1 # $25 Permit Fee: Suppl, Insp Fee PME Unit Fee: PME Permit Fee: $25.00 $48.00 __F_T Construction Tax: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fees: i Travel Documentation Fee: 1TRAVDOC $48.00 Strong Motion Fee: IBSEISMICO $2.52 , Select an Administrative Item TOTALS: $1.00 SUBTOTALS:~ $169.52 $25.00 . NOTE: This estimate does not mcmae fees aue to inner vepartmeme - L a -.Y.- Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11 -053 Eff. 7111131 Mech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check ;llech. Permit Fee: Plumb. Permit Fee: IPPERMIT Elea Permit Fee: A4ech. lrrsp. Other Plumb Insp. 0.0 hrs $48.0 Other Elec. Insp. tic:clt. Insp. pee: Phenib. Insp. Fee: Elec. Insp. Nee: Permit Fee: Suppl, Insp Fee NOTE: This estimate does not mcmae fees aue to inner vepartmeme - L a -.Y.- Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11 -053 Eff. 7111131 FEE QTY/FEE MISC ITEMS Plan. Check Fee: ,Suppl. PC P"ee PME Plan Check: $0.00 Permit Fee: Suppl, Insp Fee PME Unit Fee: PME Permit Fee: $25.00 $48.00 __F_T Construction Tax: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fees: i Travel Documentation Fee: 1TRAVDOC $48.00 Strong Motion Fee: IBSEISMICO $2.52 , Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS:~ $169.52 $0.00 TOTAL FEE:; . Revised: 05/07/201B CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19645 STEVENS CREEK BLVD CONTRACTOR: �'g,�6tfJ p aw �4�E PERMIT NO: 15060017 A& f(wi � x,20 OWNER'S NAME: PORTAL PLAZA LP DATE ISSUED: 06/02/2015 OWNER'S PHONE: 4088575849 PHONE NO: F LICENSED CONTRACTOR'S DECLARATION ,� Nk -_� JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL REPLACEMENT OF BROKEN 4" SEWER MAIN LINE License Class '2 Lie_j jy LOCATED AT THE CLEANOUT Contractor E ; 1 1 I ate I hereby affirm that I am licensed under the pro ' ions 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 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 Sq. Ft Floor Area: Valuation: $9000 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 APN Number: 31620083 19645 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I 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 c �� C� gg �� 0 1C��4.� U1yHt/r� Issued by: YT`-{� Date: granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section RE- ROOFS: 918. _�- Y . }'� P —` Signature Dat 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. ❑ 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 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 (See.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 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & 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 material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this + .` ,j Owner or authorized agent: -- — - �% � ' Date: 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 CONSTRUCTION LENDING AGENCY 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 I hereby 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's 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 to building construction, and hereby authorize representatives of this city to enter upon 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 understand 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 Licensed Professional 9 18. Signature Date CUPERTINO GENERAL PERMIT APPLICATION 1 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(tupertino.org PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑AIISCELLANEOUS �j r ur v; Y PRO CT RESS , � I �W5 G APN - l® � U 16 o OWNERNAMq> I 6 oral PHONE _ .., E -MAIL STREET ADDRESS 'o �v21 CITY, STATE, ZIP Q, -,V, \e., FAX ca auo b(o CONTACT NAME 011...- o::b co r�-CrwAUv w oav& PHONE E -MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ o-Aq,,ER- BUIIAER ❑ OWATERAGENT ❑ CONqRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORIgAI.f LIC ER D G� i� 2Z5 ^ �1CZ TWF. 3 `(o BUS. LIC 4 . b FAX COMP TY NAME E -MAIL eh 1642 sbc STREET ADD SS CITY STATE, ZIP PHO ARCHITECT/ENGATEER NAME LICENSE NUMBER BUS. LIC tt COMPANY NAME E -MAIL FAX STREETADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY PROJECT IN WII.DLAND ❑ YES PROJECT IN ❑ YEs IS THE BLDG AN ❑ YES BUILDING: ❑ COMMERCIAL URBAN JNTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO DESCRIPTION OF �✓ % L�Ci ti! VJ 7.�' 4.z�'� (L /o' ✓J r?� '� �O /� P✓IJ�% �7Ci r TOTAL VALUATION: \ By my signature below, I certify to each of the following: I am the property owner or authorized a.ent to act on the i1foperty 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 relatingatobuil construction. I authorize representatives of Cupertino to enter the above - identified property for inspection purposes. \ding Signature of Applicant/Agent: ` -- -. Date: �— SUP EMEAIT IINTFORMATION REQUIRED OFFICE USEOI�L1 gn 1 OVER LHE CO[J�TER �. WIF gg Ong a t Plm I� ig MEPMiscApp_2011.doe revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION 21 ADDRESS: 19645 STEVENS CREEK BLVD DATE: 06/02/2015 REVIEWED BY: PAUL APN: 316 20 083 BP #: ''VALUATION: $9,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building PENTAMATION 1 CPSS USE: PERMIT TYPE: WORK REPLACEMENT OF BROKEN 4" SEWER MAIN LINE LOCATED AT THE CLEANOUT SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 hrs $0.00 QTY UNITS BP FEES Elea Permit Fee: Sewer, Sanitary 1PCSEWER Other Elec. Insp. 1 # $25 Permit Fee: Suppl, Insp Fee PME Unit Fee: PME Permit Fee: $25.00 $48.00 __F_T Construction Tax: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fees: i Travel Documentation Fee: 1TRAVDOC $48.00 Strong Motion Fee: IBSEISMICO $2.52 , Select an Administrative Item TOTALS: $1.00 SUBTOTALS:~ $169.52 $25.00 . NOTE: This estimate does not mcmae fees aue to inner vepartmeme - L a -.Y.- Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11 -053 Eff. 7111131 Mech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check ;llech. Permit Fee: Plumb. Permit Fee: IPPERMIT Elea Permit Fee: A4ech. lrrsp. Other Plumb Insp. 0.0 hrs $48.0 Other Elec. Insp. tic:clt. Insp. pee: Phenib. Insp. Fee: Elec. Insp. Nee: Permit Fee: Suppl, Insp Fee NOTE: This estimate does not mcmae fees aue to inner vepartmeme - L a -.Y.- Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11 -053 Eff. 7111131 FEE QTY/FEE MISC ITEMS Plan. Check Fee: ,Suppl. PC P"ee PME Plan Check: $0.00 Permit Fee: Suppl, Insp Fee PME Unit Fee: PME Permit Fee: $25.00 $48.00 __F_T Construction Tax: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fees: i Travel Documentation Fee: 1TRAVDOC $48.00 Strong Motion Fee: IBSEISMICO $2.52 , Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS:~ $169.52 $0.00 TOTAL FEE:; . Revised: 05/07/201B