15110140CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: 15110140
11010 N DE ANZA BLVD CUPERTINO CA 95014 (309 42 04 1)
OWNER'S NAME: (CUPERTINO DE ORO CLUB INC)
DATE ISSUED: V! 0g / J
OWNER'S PHONE:
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. �ZZ &�p��
Contractor Dates !� /3fD�i
—BLDG
BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
— RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
REMOVE AND REPLACE (6) GAS DISPENSERS AND ISLANDS
I hereby affirm under penalty of perjury one of the following two declarations:
AT CHEVRON STATION.
1. I have and will maintain a certificate of consent to self - insure for Worker's
ompensation, as provided for by Section 3700 of the Labor Code, for the
erformance of the work for which this permit is issued.
011-
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
Sq. Ft Floor Area:
Valuation: $89000.00
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
APN Number:
Occupancy Type:
ordinances and state laws relating to building construction, and hereby
309 42 041
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, costs, and
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
180 DAYS FROM LAST CALLED INSPECTION.
Code, Section 9.18.
c
Issued by _1'
/� ! W/10:01
Signatur Date�Date:
OWNER - BUILDER DECLARATION
RE- ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety Code, Sections 25505, 25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
Owner or autrorized agent
be deemed revoked.
Date r /��
//
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.18.
Licensed
Professional
Signature Date
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 L oqu,
(408) 777 -3228 • FAX (408) 777 -3333 • buildingCD_cupertino.org l)' ] /
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS 11010 N. DE ANZA BLVD.
APN # 30942041
OWNFJt NAME; - - - - -- -- - -- -- -- —
PHONE 925.842 -1000
E -MAIL
STREET ADDRESS; O �O - -- -
- -- -- - -'- - -' - -�
CITY, STATE, ZIP,; j �r � � i j
�J4r
FAX
CONTACT NAME LIDDYMCKENZIE
PHONE 925.551 -7555
E- MAIL LIDDY @GRINC.COM
STREET ADDRESS 6805 SIERRA COURT, SUITE G
CITY, STATE, ZIP DUBLIN, CA. 94568
FAX 925.551 -7888
❑ OWNER ❑ OWNER- BUILDER ❑ OWNER AGENT O CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME MERLIN BOWEN
LICENSE NUMBER 220793
LICENSE TYPEA,B,HAZ
BUS.LIC#
COMPANY NAME GETTLER -RYAN INC
E- MAIL MBOWEN @GRINC.COM
FAX 925.551-7888
STREET ADDRESS 6805 SIERRA COURT, SUITE G
CITY, STATE, ZIP DUBLIN, CA. 94568
PHONE 925.551-7555
ARCHITECT/ENGINEERNAME JEFFREY M. RYAN
LICENSE NUMBER C -13933
BUS. LIC#
COMPANY NAME GETTLER-RYAN INC
E -MAIL JRYAN @GRINC.COM
FAX 925.551 -7888
STREET ADDRESS 6805 SIERRA COURT, SUITE G
CITY, STATE, ZIP DUBLIN, CA. 94568
PHONE 925.551-7555
DESCRIPTION OF WORK REMOVE & REPLACE 6 DISPENSERS AND ISLANDS WITH 6 NEW DISPENSERS AND ISLANDS. CONVERT
A GASOLINE UNDERGROUND TANK TO DIESEL. MINOR FLAT WORK. MINOR ELECTRICAL FOR NEW DISPENSERS USING
EXISTING CONDUIT AND BREAKERS.
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
GAS STATION
GAS STATIC)
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: DETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑YES
SECONDSTORY [I YES
O
BEING ADDED? ONO
ADDITION? ENO
PRE - APPLICATION []YES IF YES, PROVIDE COPY OF
1S THE BLDG AN ❑ YES
RECEIVED'BY: - - --
TOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? M NO
$89,000.00
By my signature below, I certify to each of the following: am the property owner or authorized gent to act on the property owner's behalf. I have read this
application and the information I have provided is corr. I have read the Description of r and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building cons Ion. I authorize re i of Cupertino to enter the above - identified property for inspection purposes.
Signature of Applicant/Agent: Date: k
SUPPLEMENI� O RMATIOTIT
PLAN CHECK TY E ` `
ROUTING SLIP
❑°
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
OVER - THE - COUNTER
you BUILDING PLAN REVIEW
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 4; f�f(2 /✓l�iT
Copy of Planning Approval Letter or Meeting with Planning prior to
❑' MAJOR
❑ SANITARY sEwEliDISTRICT
submittal of Building Permit application.
i�❑
ENVIRONMENTAL HEALTH'
BldgApp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
10
ADDRESS: 11010 N De Anza Blvd
DATE: 11/19/2015
REVIEWED BY: Sean
MISC ITEMS
APN:
BP #:
*VALUATION: $89,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY
—t USE: Commercial Building
Civil /Religious activities
in BQ zone? •;
• � Yes E) No
PENTAMATION
PERMIT TYPE: 1GENCOM
WORK
Remove and replace 6 as dispensers and islands at Chevron Station.
SCOPE
Hech. flan C:dcc ;h
ilech. Perrriii .tee:
Pdunib. Plan (Check.
Pluiub. Pei•ntir Fees:
0iher Veeh, bist.a. I I O tier Plata ?b btsp. LJ L
Hec/a. fnw. F'ee: u 1'111' ab. Itisp. Fee:
NnTF.r Thic octimate dnoc mint inrlude foot due to nther Donartmemitc fi_o_ Plannina
Elec. Plan Check
].'" ec, Permit Fee:
Other
t•;lec. inch. F'se:
Wnrkc. Firo_ Ranitary .Sower Dictrirt..Vrhnni
Ulstrict, etc.). Ihese -fees are based on the preliminary information availaote ana are only an estimate. contact i to Uept_for aaan,t info.
FEE ITEMS (Fee Resolution 11 -053 E, . 7/1/13}
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes (F) No
$0.00
hours Plan Check, Hourly
$286.00 1STPLNCK
Suppl. PC Fee: Reg. OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? 0 Yes (E) No
$0.00
Suppl. Insp. Fee:E) Reg. Q OT
0,0
I hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: 1BCONSTAXC
$0.00
AtIminisfrative T'ee:
0
'°
Work Without Permit? 0 Yes E) No
$0.00
Advanced Planning Fee:
$0.00
0 hours Inspections
$429.00 1 STINSP Inspection, Hourly
E)
0
I irrrel .I)oc;utirc>>ltari��n 1 'ee ;s:
Strong Motion Fee: - 1BSEISMICO
$24.92
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$4.00
SUBTOTALS ,
.A
$28.92
$715.00
TOTAL-FEE .°
$743.92
Revised: 10/01/2015