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03100149 (2) CITY OF CUPERTINO BUILDING DIVISION pERNID ra�QN'TRt1.C3TQ�2INF,O ' " 1Y , BUILDING ADDRESS: LAMCKE CONSTRUCTION `- PERMIT NO"03100149 OWNER'S NAME: 85.5 CIVIC CENTER DR , PERMIT ISSUE DATE N E: (408) 985-7625 SANITARY NO. CONTROL NO. ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 Ino LICENSED CONTRACTOR'S DECLARATION 1 b m r «rte he,1.m licensed ander provisions or charter 9(commencing Job Description withSecnity Bof Divmmn 3 of the Busse and Profession Code.and my license is imfull force mnderfea REVISION--IN HOUSE USE ONLY Z Lkenu Cissa Lic.X 3g DamComraem0 RATINO NEW PERMIT ISSUED/ORIG. 303070046 ARCHITECTS DECLAON r 1 on cramnJ my pians shall he used ns public rccards - ayU o Licensed Professional s OWNER-BUILDER exempt DECLARATION Contractor's ON )0I 1 naso .(firm,bum 11. cammp,tram the Cusions License Lew for de 400 o which ng reason.(Secpermit t 103 construct, Business and r w.de o li h.Code:Any tiny or county f$ which rcyuTrcson permit ter quires t a,comm,imfimsf demolish,or repair any structure -ZKr trienni liaan2,also mmit1.ms thnviamcamfor Cmunwoh m'srt LiceseLaw(Chaptned cm 1—< thatmenciing wit punas mdiva 00)c(Disionsnf theCB usimc iLittnmisw(Chaprery Sq. F[.Floor Area Valuatio 107 (com3�$ Us,heIn�ingwi,hSenion meAndde,basisfon rnf,heeedcoveead.n.AnynnsCOJc)of .. Na,he ie exempt thertfrmm and Ne bait for the alleged exemption.Any violation of section)031.5 by any applicant for a Ismaili subjects the applicant to a civil penalty of 3 Abp$NDfbiler 00 Occupancy Type net more Nan five hundred dollen($500). ❑1,me owner or the property,or my employees with wages as Heir sole compensation, will do fee work,and Ne swnure is not intended or offered for sale(Sec.7614,Business and Pm(essions Code:The Contractor's License Law does not apply no an owner of Required Inspections properay who build&or improves demean,and who does such work himself or through his own employees,provided that such improvements arc nen intended or offered(or ale.It, however,de building or improwmem is mid within one year of completion,the owner builder will bare the burden of proving that he did not build or improve for purpose of lzisale.). ).as owner of the property,am exclusively contracting withlicensed contractors to )AIrodrue,,he project(Sec.7044,Business and Professions Code:)Thr Conuacwr's Li. cense Law dors net apply to an owner of property who builds or improves demon.and who contracts for such pmjscu with a eonuacmr(s)licensed punuar,to the Convenor's License Law. I am exemptu r ee. B&PCfnrthi eco 'Owner / D�fe D 61�OCOMPENSATION D TON -) I hereby affnd under penalty of perjury one of the following declaations: 1 have and will maintain a Ccnlficate of Consent to sel6insure for Worker's Compen- ation,As provided for by Section J700 of the labor Code,for,he performance of the work for which this pemri,is issued. 1 have and will maintain Workers Compensation Insurance,a required by Section 3700 of the Labor Code,for the performance of de work for which this permit is issued. al� r bfff Cnmpenaation Insurance carrier and Policy number an: Poli _ CERTIFIC OMPEOF SATIONI WO0.KER5' COMPENSATION INSURANCE (This section need nm hccompleted if,hc permit la formo hundred dollam(510!1) Ica.) 1 certify Na,in the performance of the work for which,his remand H issued.1 sha11 no, employ any person in any manner m As in become mbjee,India Workeri Compensation Laws e4 California.Date Applicant NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should become subject no the Worker's Compensation provisions of the Labor Codc,you mum O forthwith comply with such provisions or this Permit shelf be deemed ranked. CONSTRUCTION LENDING AGENCY tea thereby affirm that dere is a conswcdnn lending agency for the perfommmee of 2:> dm work fur which this permit is issued(Sm.3097,Civ.C.) YQ Lerom shame = Z Lender's Address ;J C 1 certify that 1 have read this application and sum that the above information is L j.. Comet.I Agree 10 comply with all city and county ordinances and suite laws relining to U building construction.and hereby authorim mpresnui,iws of this city to cnmr upon de shove-mentioned property for inspection purpnms ahic)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,coats and cxpenSa which may In any way scene,against mid City APPLICAconsequence UNDthe gSTANDS�hIs D WILL COMPLY WITH ALL NON- DINor T Issued by: Date soURC E UL IONS. w'2v e-roofs sign icmo Conmacmr am HAZARDOUS MATERIALS DISCLOSURE Type of Roof WIII the applicant ser future building occupmn moor handle hnautlous memdm As defined by the Cupertino Municipal Code.Chapter 9.12.and,he Health and Safety COJe,Section 255J2(a)? ❑ x 'AN. All roofs shall be inspected prior to any roofing material being Installed. WIII the applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove it hevardous air contaminants As defined by fire Bay Arca Air Quality Management all new materials for inspection. iiUicl? 11 C]Yea pJNo I have mad the hamdnus materials requirements under Chapter 6.95 of the Cali for nia Heald&Safety Cade,Sections 25515,25533 and 25534,1 undcramnd that ifthe building dors , tune ly haw a¢ m,thu it u my responsibility m r 'fy tM �upm,m the mq ' maI hichmu me,pdortuiduancecfaCrdfca efOcca cy. SignatureofApplicant Date o aededxed agent D ZD ,e All roof coverings to be Class"B" or better ym ter.-:....-..,m:4�ry vY`^".�...'7K�m_ -.•^"'a'r -nar+n��mrM'e�.-...,r.: n..r:.ww,m:nswv^SMV..A.V"1»'1,^iMhV1F.�M^a'w...,.-,-,!'rwn. / ew� . .-.. „ .....--'YrAa•ltM'YN'1'LYI%,y(Y+.,y" \ J ' INSPECTIONS DSA File # DSA Appl. # A Division of REED & GRAHAM, INC. 690 SUNOL STREET•SAN JOSE, CA 95126 OSHPD # (408) 288-8460 • FAx:(408) 271-0902 ANCHOR INSTALLATION INSPECTION REPORT City of: F I L E Date: Project Name: /yS �/ JT6�tS y�cE # �1tirJ - 7 Address: /OS�! /� �Tl,/CeS �" �U , Permit# C)5 74� t1 Inspectors Name: 14-fl cff,aE� T t�j� ID# / Installation Inspection of: ❑Epoxied Reinforcing Steel Dowels YZpoxiedAllthread Anchors 13 Expansion Anchors ❑V1litnessed the drilling of the holes and verified proper diameter and depth. (or) �nspected predrilled holes and verified proper diameter and depth. o 6��served the cleaning of the holes and the injection/insertion of V'�/ � �uxy /E � - ZZ- epoxy-/epoxy capsules / grout, ICBO# Expiration Date 2,y iNitnessed the proper i sertion of: L (No.) S o diamet allthread anchor / reinforcing steel dowels / expansion anchors, inches in length, embedded C7 / inches,at the following location: L67A - - GUtST Luft-ll •- #de4clao (No.) s g diamete Ilthrea anchors> reinforcing steel dowels / expansion anchors inches in length,embedded —7 / inches, at the following location: -A e-5 U,1A// .,- UcY1c/Z 7S /D /N Rcwal yll S -- cNaR TS (No.) 8 diamete allthread anch / reinforcing steel dowel / expansion ancho inches in length,embedded inches,at the following location ----------------------------------------- Notes:---------------------------------------- Notes: ———————————————kisins ———————————— ———————— To the best of my knowqabl rk in/ship ctedrdance with the building department approved design drawings, specifications and appliorkma pthe U.B.C./C.B.C. except as noted above: Inspectors' signature: ry+j 03 "70 `CITY OF CUPERTIN* 9 CITY OF PERMIT APPLICATION FORM o3 � " o q/ CUPERTINO NSAPN # Date: qj- d Building Address: 0 5 i`o Owner's Name: Phone#: 2 / o - 3� Contractor: License#: f4 M4- s . a Contact: Cupertino Business License#: Building Permit Info: Bldg ❑ El ❑ Plumb ❑ Mech ❑ Job Description: Residential El Commercial Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 4Z3s'3 � 1of3 ITY OF CUPERTINO6 CITY°F' PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BNNEWMULTI New Multi-Farr­ffly Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE —Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation ofFumace MECHANICAL BREMFURNOV Relo Fumace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC . Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL 2of3 u , , 3z VITY OF CUPERTINO r CITY OF PERMIT APPLICATION FORM CUPEI�TINO Quantity Fee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING I, • 3 of 3 + �? ctry OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM 0 3 `' 7 d fik APN # r Date:fJ J I g 2-003 5 Building Address: /_ �5 �L C elr� ✓10 Owner's Name: J�1 Phone on • f 6Mdy. e Ile yoy) g6s087Y Contractor: License#: Contact: 1 DAJ )�e Ile Cupertino Business License#: N4 B 'n Permit Info: Bldlect um ech Job cription: esidential ❑ m a ❑ Sq.Ft. Floor Area: $/Sq. t.: Cost of Project: Occupancy Group: r Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERl Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax —Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL . BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC I Comm. Housing Mit. Fee BUILDING 1of3 u6 , 1 #- CITY OF CUPERTINO , CITY OF PERMIT APPLICATION FORM CUPEIZTINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAiRHAN A/C Units<= 10,000 cfin MECHANICAL _ BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFD{T Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> 1 OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREN20LE Pole/Platform Fixture ELECTRICAL 2 of 3 CITY OF CUPERTO CUP TYOF . PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch &Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3