08110086BUILDING DIVISION PERMIT
PERMIT NO.
OWNER'S NAME: I INC I PERIMISE OE DATE
ARCHITECT/ENGINEER:
u O O LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter (commencing
Z with Section 7000) of Di on 3 of the Business andProessionLCOde, and my license is
age! in full force and eRccv�' 4 4I
r� Z License Class LIC. A
F in Date Contractor
ARCHITECTS DECLARATION
H< I understand my plans shill be used as public records
�dU
# aV y Ucensed Professional
5 y � OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
i O O following reason. (Section 70313, Business and Professions Code: My City or County
o V which requires a permit to eonstrucL, alts, improve, demolish, or repair any structure
= y prior to its issuance, also requires the applicant for such permit to file a signed statement
Y< that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9
. G (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y that he L exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the appliam to a civil penalty of
not more than five hundred dollars 4S00).
❑ L u owner of the property. or my employes with wages as their sok compensation,
will do the work and the structure Is not intended or offered for sok (Sec. 7044, Business
and Profession& Code: The Contractors License Law does not apply to an owner of
ply who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale If.
however, the building or improvement Is sold within one year of compledo t. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors Ll-
cense
4cense Law does not appy to an owner of property who builds or Improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 son exempt under Ser. B & P C for this mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affrm under penalty of perjury one of the following declaration
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, u 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 Workces Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Lssuel
My Workers Compensation Insurance carrier and Policy number am:
Cartier. MA) C—;%e I 144'• Policy No.;
CERI7F7CA7E OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Phis section need nor be completed U the permit Is forotc hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit Is issued, l shall not
employ any person in any manner so as to becormc subject to the: Worixrs' Caopensatloo
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Tabor Code, you must
O forthwith comply with such provisions ord
this permit shall be deemed revoke
z .r CONSTRUCTION LENDING AGENCY
Fr oV%r I hereby affirm that there is a construction lending agency for the performance of
p$ that work for which this permit is issued (See. 3097, Civ. C)
aQ Lenders Name
z Lenders Address
U O I certify that I have read this application and state that the above information is
(y F corect. I agree to comply with W city and county ordinances and state laws relating to
0 U building construction, and hereby authorize representatives of this City to enter upon the
W ahave-mentioned property for inspection purposes.
a (We) agree to save, indemnify and kap harmless the City of Cupertino against
n,r to tiabilities,judgments, costs and expenses which may in anyway accrue against said City
C.i in consequence of the granting of this permlL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SGURc`1WmoNS. - � 161 2
.Fri a
Signature of ApphianVConuaclor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.17, and the Health and Safety
Code, Section 25532(a)7
❑Yes ONO
Will the applicant or future building occupant use equipment or devices which
emit hasrdous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
I have read the hazardous materialsrcqunemems underChapler 6.95 of the Califor-
nia Health& Safcty Code. Sectiam 25505, 25533 and 25534.1 understand t at if the building
dors not currently have a tenant that it is my re3pol bility to notify the Occupant of the
requirements be mel prior to issuance of a Crrtifiate pf Oqupancy.
116 1 C79
Owner or authorized agent Date
408)37.9-5500
Job Description
COMM'L TI; ELECT/HVAC OFFICE SPACE
Sq. Ft. Floor Area
250000
CONTROL
BURRING PERMIT IM
ELECT PLUMB
Valuation
APN Number Occupancy Type
32610046.01
Required Inspections
Re -roofs
Type of Roof
Date
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
CITY OF
CUPERTINO
CITY OF CUPERTINO
TENANT IMPROVEMENT
PERMIT APPLICATION FORM
v,f//0oR�
APN # r _ ` O o L16 Lit
Date:
''
-
z� of
Building Address:
Mailing Address (if different from building ad ess):
Tenant EJ (If tenant please provide a letter from the building owner approving the tenant improvement.)
Building Owner ❑
Tenant/Building Owner's Name: f\
&� N-. `
Phone #:
FS7`f
Contractor:
Phone #:
QQ
CovT►{ 9 T
Fax #: 3? It
Contractor License #: -3 6R Z
Cupertino Business License #:
Contact:
Phone #: 6 qd_ 8 6 7
C4w'-�v J P
1 G
Fax #: 3�`1 3a 56
Alternate Contact:
Phone #: 3 -7q —SSo0
(3wcf o
Fax #: 37
Valuation (cost of project):
ASO Joao
Job. Description (be specific):
Tenant Improvement Includes Re -Roof. Yes ❑ No If yes, number of squares
Tenant Improvement Includes Structural Yes ❑ No
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV -HT, V -B
Project Size: Express Standard Large Major
Green Building: Please complete Leed for commercial interiors checklist & attach it to the application
or if applicable, include in plans & sheet index
0
LEED Points Achieved
*** For Office Use Only*** Over The Counter ❑
Revised 8/08/08
CITY OF CUPERTINO
TENANT IMPROVEMENT
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
IATINSP
Tenant Improvement
B
1A TI
Ins ection
IATIPLNCK
Tenant Improvement Plan
B
Check
-7 q
1 BTIINSP
Tenant improvement
B
1B TI
Inspection
1 BTIPLNCK
Tenant Improvement Plan
B
6
Check
IETIINSP
Tenant Improvement
B
1E TI
Inspection -Preschool
IETIPLNCK
Tenant Improvement Plan
B
Check -Preschool
1FTIINSP
Tenant Improvement
B
1F TI
Inspection-Factory/Indust
1 FTIPLNCK
Tenant Improvement Plan
B
Check-Factory/Indust
1HTIINSP
Tenant Improvement
B
1H TI
Inspection -Hazardous
1 HTIPLNCK
Tenant Improvement Plan
B
Check -Hazardous
1ITIINSP
Tenant Improvement
B
11 TI
Inspection -Institutional
I 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
1 REROOFCOM
Re -Roof Commercial
B
1BSEISMICO
Seismic Commercial
B
BUS LIC
Business License
B
2 of 2
Plan Review Process Work Book Page -12-Revised 3/25/08
Green Building Plan Check
Index of Green Building
Points/Categories
A.
Category
Example of an Index or Table of Green
Plan Sheet or Page
Points
Building Points Categories that must be
shown and referenced on the Project
MEN
am Plans See below ilMlm
B.
Site
9.
Install H.E. Irrigation, (details/spec)'
L-1
2 points
11. Permeable. Paving, Note
L-1
2 points
C.
Foundation
1.
Use 15 % Flyash Concrete, (note)
S-1
5 points
D.
Structural
3.
Uses Wood I -Joist, (See Spec.)
S-2
2 points
5.
Use Truss with heels, (detail)
S-2
2 points
6.
B. OSB Sheathing, detail
S-2
2 points
E.
Ext. Finish
1.
Composite Decking, (Note/Spec.)
A-3
2 points
4.
B. Fiber Cement Siding, (Note/Spec.
A-4
2 points
F.
Plumbing
1.
Insulate all H.W. pipes, (Note/Spec.)
P-1
2 points
5.
Tankless W.H., (Note/Spec.)
A-2
2 points
11. A 2500 Gal. Tank, (Note/Spec
L-1
10 points
G.
Electrical
4.
E. Ceiling Fans, (Note/Spec.)
A-3
4 points
H.
Appliances
1.
Energy Star Dishwasher, (Note/Spec.)
A-3
1 point
3.
Energy Star Refrigerator, (Note/Spec.
A-3
1 point
P.
Other
1.
List Green Features on Plans
A-1
1 point
TOTAL POINTS
1 40 points
Plan Review Process Work Book Page -12-Revised 3/25/08