08070080CITY OF CUPERTINO
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BUILDING DIVISION PERNIIT
PERMIT
kCQN �['1J TQR
BUILDING ADDRESS:
PERMIT NO.
10123 N WOLFE RD UNIT F 21
TBD — TO BE D
'
ER'S NAME:
PERMIT L4E DATE
PHONE:
IkU.2808 CONTROL NO.
ARCHTIEC MNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
Mouth, strum cast 1 w licensed under provisions of Chapter 9 (m nummi.g
with Section 7") of Division 3 of dre Business and Profession Code, and my license is
in full farce am Cffea
T.I. SUBWAY SANDWICHES— REMODEL 703 SQ FT IN FOOD
Lima. Class Uk.N
Data .aecur
D
COURT AREA (FC1) .
ARCHITECTS DECLARATION
1 understand my plans shall W used as public accords
Licensed Professional
OWNER-BUILDER DECLARATION
I Immy fram Nat 1 am exempt from the Crunchier Beene law for the
following reason. (Samar, 703 1.5, Botrcss and Professions Cock: Any city or many
which requires a permit m eorawm abee improve. demolish, or repair any swetum
prior Or is issuance, also mquircs LM applicant for such permit to File a signed arum=,
Sq. Ft. Floor Area
Valuation
that k is licensed pursuant to the provisions of du Convectors license Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Profe sins CMc) or
$80000
that he k exempt rhemfrom and the bur for the alleged Crompton. Any violation of
APN Number
Occupancy Type
Section 7071.5 by say, applicant for a Permit subjects the apPlkant m a civil penalty of
ML more then five hundred dollars (g30M).
31620096 . FC 1
Lu ownerofthe uty,ae employee with wageutk'v sole
Required Inspections
Business
will due I, or Queued ace, Butrcss
thcwons. and the
Con u
er's Lrbcd
s .1 a(Sec. in
sad Pmfrsdans case: The canuxmra License Law a«a set apply m an awrw or
and pr he
property who Wildsorimprove therson,and whodoessuch work himselfor through his
awn employes, provided Wt such improveromm are not intended aroffued for sale IL
however, the building or improvement is sold within NO yes of completion, due owner -
builder unit have the barded of proving Nat M did rot Mild or improve for purpose of
sak.).
1, as owner of the proNny, am exclusively contracting with licensed ronuutors to
.street the project (See. 7004, Business and Prolusions Cade) The Co basso es U-
tee Taw does not apply to an owner of property who Wilds or improves thereon, and,
who contacts forsueh projects with a commitments) licensed pursuant to IML'antracmrs
Licemas Law.
1 am see a R P C for this raison
/J/// / Date /- O
WORK SCOMPENSATTON DECLARATION
1 hereby strum under Nulty of perjury arc of the following declantians:
-1 have and will maintain a Certificate of Cavent m self -insure for Workers Compcn-
L ion, as provided for by Second 3700 of the labor Code, for the performance of the
work for which this Permit is imad.
1 have and will maintain WorMrs Compensation Insurance, as required by Section
3700 of the Labor Codt for the performance oftiw work for which this permit is issued
'
My War tam's Compensation Insurance artier and Policy number art:
Clrrio, Policy No.:
CERTIFICATE OF I KEMFOON FROM WORKERS'
COMPENSATION INSURANCE
(Thitsection seed 0alkcomplesed if the permit is faronc hundred dollars ($10()
or it.)
I certify Nat in the performance of the work for which this permit Is issued. l shall not
employ any person in any manor as come subject tube Workcri Compensa0on
Laws of fah mu m
Applic 6 a,64 ! L .a
NOITC IJCANT: It, aflcs.mak g this Certificate of Exemption, you should
become subject m the Workers Compensation puovisiou of dm Labor Cede, you rout
foMwica comply wit such provisions or this Permit stall M lamed am aked.
CONSTRUCTION LENDING AGENCY
1 ber Net mum's lending ageray for case perfermaruc of
dig m
' the work for which Nis pennil U issued (Sec. 7097, Civ. C.)
which s ed (Sec.3
'
Lender's Name
,
Landers Address
1 certify that 1 have mad this application and sum Nat the above info roman is
'
' corner I agree to comply with all city and county aNinance and sale laws relating to
Wilding construction. and hereby interim repmemouives of this city in tour upon the
j akve- mcntioncd pmpeny for inspection purposes
(We) agree to save. indemnify and keep harmless 1M City of Cupertino against
j Iiabiiitie, judgmena.cora and ..,souse which may in any may a ate against said City
in '
APPLICANT UN ERSTAMY"ND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
so urn s.
Re -roofs
Type of Roof
0 $
2ijimblim of Appli onaac Date
AZARDOUS MATERIALS DISCLOSURE
Will NC applicant Or future building ocmpantamre or handle ma rdou maunal
by 11, Cupertino Municipal Code, Chapter 9.11, and the Health and Safety
Wdcrnal
. Sccman 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Ye �Ne
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding sampan urc equipment or merles which
emit havaadoe air ronumiunu as defined by the Bay Area Air Quality Maesgcmem
all new materials for inspection.
DinnclT 1
CYa No
1 have mad the huaud:aumaurialsmquimmena undcrchapter6.95 of the Califor-
nia Hub" Safety Code. SncMm 8503.25573 and 15530.1 understand NuifNc building
dot mMend, have a mnanr„dul it u my responsibility to notify the coupon of Me
e am
rryai hmustM tPon asaanccofaceniMamofOcm,xm,y.
Signature of Applicant Date
All roof coverings to be Class 'W' or better
19vm ' '
Dow—
r rawnorvcda� Dais
CITY Of
CUPERTINO
CITY OF CUPERTINO
TENANT IMPROVEMENT
PERMIT APPLICATION FORM
Oe�07 0 o8"o
APN # 3 t - 2 b- 10.0- 1 �
Date: °71 l 4l o 8
Building Address:
_ C
10123 hl . U/0 t, r 12p •, CuPffIZ T1140 , cA
(CL)rF_,eipto 50 0,&V -0
Mailing Address (if different from building address):
Owner's Name:
Phone #:
KHo JA sTeh `
(109 ) 314-61(v8
Contractor:
Phone #:
Fax #:
Contractor License #:
Cupertino Business License #:
Contact:
Phone #: ( 9 o 8)
o4"IIZ- KHOJAST60
Fax #: 0408 379 - 1 q4 s—
Alternate Contact:
Phone #:
Fax #:
Valuation (cost of project):
Job Description (be specific):
TOTAL V_c-ric)Dc L A 5 i63 S -F- Al C0PE%Z.T1I-10 5QUACE FOOD Coo IFT
Fo 4 5LJ8 LOS,
Tenant Improvement Includes Re -Roof: Yes ❑ No EN If yes, number of squares
Tenant Improvement Includes Structural Yes ❑ No M
Type of Construction (Usage Class):
Occupancy Type:
I -A, 1 -B ❑ II/III/V -A ❑ II/III B, IV -HT, V -B
Project Size: Express ❑ Standard M Large ❑
Major ❑
Green Building: Please complete Leed for commercial interiors checklist & attach it to the application
or if applicable, include in plans & sheet index
-
LEED Points Achieved
* ** For Office Use Only * ** Over The Counter ❑ Revised 6/16/08
CITY OF CUPERTINO
TENANT IMPROVEMENT
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
IATINSP
Tenant Improvement
B
1A TI
Inspection
IATIPLNCK
Tenant Improvement Plan
B
Check
1BTIINSP
Tenant improvement
B
1B TI
Inspection
1BTIPLNCK
Tenant Improvement Plan
B
Check
1 ETIINSP
Tenant Improvement
B
1E TI
Inspection-Preschool
1 ETIPLNCK
Tenant Improvement Plan
B
Check- Preschool
1 FTIINSP
Tenant Improvement
B
1F TI
Inspection- Factory/Indust
1FTIPLNCK
Tenant - Improvement Plan
B
Check-Factory/Indust
1 HTIINSP
Tenant Improvement
B
1H TI
Inspection- Hazardous
1HTIPLNCK
Tenant Improvement Plan
B
Check - Hazardous
1ITIINSP
Tenant Improvement
B
lI TI ,
Inspection- Institutional
l ITIPLNCK
Tenant Improvement Plan
B
Check - Institutional
1MTIINSP
Tenant Improvement
B
1M TI
Inspection- Merchandise
1 MTIPLNCK
Tenant Improvement Plan
B
Check - Merchandise
1 STIINSP
Tenant Improvement
B
1S TI
Inspection- Parking Garag
1 STIPLNCK
Tenant Improvement Plan
B
Check.- Parking Garage
1REROOFCOM
Re -Roof Commercial
B
1BSEISMICO
Seismic Commercial
B
BUS LIC
Business License
B
2 of 2
Community Development
10300 Torre Avenue
Cupertino CA 95014
5��
Telephone (408) 777 -3228
CITY OF Fax (408) 777 -3333
CUPEkTINO
Building Department
I am not using any subcontractors:
e Date
Please check applicable subcontractors and complete the following information:
JOB ADDRESS:
/0/23 A). cJvLF 20 . cOpP-zezT11jo
PERMIT #
O� O-7 ,� L-� 20
BUSINESS LICENSE #
OWNER'SNAME: ANI2 KHOZAs5TE
PHONE # 9OF� 37q -(942
GENERAL CONTRACTOR i P
FAX # e P, 3 7 - f q y' S
I am not using any subcontractors:
e Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature
Date