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10070048CITY OF CUPERTINO BUILDING P BUILDING ADDRESS: 19648 STEVENS CREEK BLVD I ()WNER'S NAME: KCR DEVELOPMENT s- iER'S PHONE: 4083431088 LICENSED CONTRACTORDECL 'S License Class Lie. # 6_AkwAKATION � Contractor -4 it 0 b 1 hereby affirm that 1 am licensed under the provisions 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. 1 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. 1 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. APPLICANT CERTIFICATION 1 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue a aid City in consequence of the granting of this permit. Additional , t a icant understands and will comply with all non -point source regul on e e Cupertino Municipal Code, Section 9.18. Signature Date lD ed OWNER -BUILDER DECLARATION CONT'2ACTOR: JK BAKI CONSTRUCTION INC 2175 S'rONE AVE UNIT I I SAN J -)SE, CA 95125 hereby affirm that I am exempt from the Contractor's License Law for one of he following two reasons: , as owner of the property, or my employees with wages as their sole compensation, ,vial do the work, and the structure is not intended or offered for sale (Sec.7044, 3usiness & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to ;onstruct the project (Sec.7044, Business & Professions Code). BUILDING PERMIT INFO: BLDG f— PERMIT NO: 10070048 DATE ISSUED: 10/05/2010 IPHONE NO: (408)882-0199 ELECT r— PLUMB MECH r— RESIDENTIAL f— COMMERCIAL F JOB ]ASCRIPTION: INSTALL DEMISING PARTITION IN (E) MALL TO SEPAF ATE INTO i 2)TWO TENANTS,400SQ 1 hereby affirm under penalty of perjury one of the following three 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. 1 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, l become subject to the Worker's Compensation provisions of the Labor Code, l must forthwith comply with such provisions or this permit shall be deemed revoked. Sq. F Floor Area: APN Number: 36906009.1 APPLICANT CERTIFICATION I certify that 1 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 'emnify and keep harmless the City of Cupertino against liabilities, judgments, .s, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Valuation: $2500 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR L80 D YS FROM L CALLED INSPECTION. Issu ;d by: / `S Date: RE -ROOFS: All r )ofs 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 insp,:ction. Signature of Applicant:_ Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIA[ S DISCLOSURE 1 ha ve read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain con ipliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Saf :ty Code, Section 25532(x) should I store or handle hazardous material. Additionally, should1 useequi ment or devices which emit hazardous air contaminants as defined Bay Area Air Quality Management District I will ma ntain compliant a Cupertino Municipal Code, Chapter 9.12 and the He rlth & Safety ctions 25505, 25533, and 25534. Ov ner or i agent: Date:/ CONSTRUCTION LENDING AGENCY I h :reby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I t nderstand my plans shall be used as public records. Date I Licensed Professio Signature �.�� I CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 19648 STEVENS CREEK BLVD I CON TRUCTOION INC I PERMIT NO: 10070048 OWNER'S NAME: KCR DEVELOPMENT 12175 STONE AVE UNIT 11 ! DATE ISSUED: 10/05/2010 1 OWNER'S PHONE: 4083431088 1 SAN JOSE, CA 95125 1 PHONE NO: (408)882-0199 LICENSED CONTRACTOR'S IK`/ DECLARATION License Class_ Lic. #t rT� Contractor_13Q/ur-d5mucTiok�" 1 O % I hereby affirm that I am licensed under the provisions 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. BUILDING PERMIT INFO: BLDG ELECT 17, PLUMB 17 MECH RESIDENTIAL . COMMERCIAL r11 JOB DESCRIPTION: INSTALL DEMISING PARTITION IN (E) MALL TO SEPARATE INTO (2)TWO TENANTS,400SQ 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 Sq. Ft Floor Area: 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 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, costs, and expenses which may accrue a aid City in consequence of the granting of this permit. Additional , t a licant understands and will comply with all non -point source regul on e e Cupertino Municipal Code, Section 9.18. Signature Date LD " �b ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 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. 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 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, costs, and expenses which may accrue against said City, in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date Valuation: $2500 APN Number: 36906009.19648 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DYS FROM L CALLED INSPECTION. Issued by: �; / r o Date: RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equi ment or devices which emit hazardous air contaminants as in Bay Area Air Quality Management District I will maintain compliance a Cupertino Municipal Code, Chapter 9.12 and the Health & Safety ctions 25505, 25533, and 25534. Owner or i agent: Date:/ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professiona {J' CITY OF CUPERTINO CITY Of CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # j o �p r O �(� Date: j t o Building Address: Mailing A dress (if differer t from building address): Are Hazardous Materials being used as part of this project? .Yes ❑ No HOA: (Exterior work only) Yes ❑ No If es, provide letter from HOA O n is Name: Phone #: Contractor: Phone: ,� JD • Fax: Contractor License #: Cupertino Business License #: Contact: Phone: S Fax: Residential Commercial Job Description: l 1!b _ r It> Sef1Cyk,9TS. Building Permit Info: Bldg El�' Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV -HT, V -B F k Z e> Valuation: n p5z Square Footage: Project Size: Express ❑ Standard [� Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Points Achieved: For help, contact Build it Green at www.builditgreen.org Revised 07/14/09 CITY OF CUPEKrINO CITY OF CUPERTINO GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description i Fee Permit Type Group 1GENRES or 1GENCOM 1BBOILERI For the installation or relocation of'ea M boiler/compressor to & including 3 horsepower, or ea absorption sys to' & incl 100,000 Btu/h (29.3kw) 1 BBOILER2 Installation /relocation of ea M boiler/compressor over 3 horsepow'er to & incl 15 horsepower, or ea absorption sys over 100,000 Btu/h i 1BBOILER3 Installation/relocation of ea M . boiler/compressor over 15 horsepower to & incl 30 horsepower, or ea absorption sys over 500,000 Btu/h to - & incl 1,000,000 Btu/h 1 BBOILER4 Installation/relocation of ea M boiler/compressor over 30 hosepower to & incl 50 horsepower, or for ea j absorption sys over 1,000,000 Btu/h to & incl 1,750,000 Btu/h 1BBOILER5 Installation/relocation of ea boiler or M refrigeration compressor over 50 horsepower, or ea absorption sys over 1,750,000Btu/h j 1BAPPLOTH For ea appliance or piece of equip M regulated by this Code but not classed in other appliance categories, or for which no other fee is listed in this code. 1 ELECINSP Other Electrical Inspections (per hour) E 1MECHINSP Other Mechanical Inspections (per': M hour) 1PLMBINSP Other Plumbing & Gas Inspectionsi P (per hour) 1MEETINGIHR Application Meeting B 2 of 5