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11060053CITY OF CUPERTINO BUILDING PERMIT [It'ILDING ADDRESS: 10123 N WOLFS RD STE. 2100 OWNER'S NAME: VALL.CO SHOPPING MALL ,%R'S PHONE: 4087773081 ❑ LICENSED CONTRACTOR'S DECLARATION I icense Class Lic tJ-- Contractor Date- hcrebv 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 mv license is in full force and effect. 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 permit is issued. APPLICANT CERTIFICATION I ccrtity 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 hLidding construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnil} 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 pith all non -point source regulations per the Cupertino Municipal Code, Section U Ix Sienatur Date t_ OWNER -BUILDER DECLARATION 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). CONTRACTOR: VALLCO SHOPPING MALL I PERMIT NO: 11060053 hcrebv 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 certitN 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 Conipcnsation laws of California. If, after making this certificate of exemption, 1 become subject to the Worker's Compensation provisions of the Labor Code, I must t0rthv� ill comply with such provisions or this permit shall he deemed revoked APPLICANTCERTIFICATION 10123 N N1'OLFE RD STE 1095 CUPERTINO, CA 95014 I certity 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, and expenses which may accrue against said City in consequence of the ung of this permit Additionally, the applicant understands and will comply w itli cal non -point Mwic - rcgulatims per the Cupertino Municipal Code, Section 9 18 „A ,' �, /� l / DATE ISSUED- 08/29/2011 PHONE NO: BUILDING PERMIT INFO: BLDG F ELECT f- PLUMB � MECH r- RESIDENTIAL F- COMMERCIAL JOB DESCRIPTION: RUBY CAFE -COMM T.I FOR MALL SPACE 2100 NON-STRUCTURAL INCLUDES 1 --BAR, MECHANICAL, EL.ECTRIC,PLUMBING,RESTROOM UPGRADE, NEW Sq. Ft Floor Area: I Valuation: $82500 APN Number: 31620107.2100 I Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: _� Date L-;- 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 1 have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 2.5532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, Owne 25533nd t Date: COtgSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of vwrk's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professiona CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10123 N WOLFE RD STE 2100 CONTRACTOR: VALLCO SHOPPING MALL PERMIT NO: 11060053 OWNER'S NAME: VALLCO SHOPPING MALL 10123 N WOLFE RD STE 1095 DATE ISSUED: 08/29/2011 OWNER'S PHONE: 4087773081 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # . MECH RESIDENTIAL I— COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RUBY CAFE -COMM T.I FOR MALL SPACE 2100 (commencing with Section 7000) of Division 3 of the Business & Professions NON-STRUCTURAL INCLUDES T -BAR, MECHANICAL, Code and that my license is in full force and effect. ELECTRIC,PLUMBING,RESTROOM UPGRADE, NEW I hereby affirm under penalty of perjury one of the following two declarations: n I% 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 s �/ performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Sq. Ft Floor Area: Valuation: $82500 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 31620107.2100 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Issued by: Date L� 7 Signaturg.,1 Date OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for I, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: Date: I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700'of the Labor Code, for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain I have and will maintain Worker's Compensation Insurance; as provided for by compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Section 3700 of the Labor Code, for the performance of the work for which this Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued, I shall maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health & Safety Code, Sections 25505, 25533, and 25534. 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 Own*0i*& forthwith comply with such provisions or this permit shall be deemed revoked. Date: CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state thattheabove information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply ARCHITECT'S DECLARATION with all non -point sourc regulations per the Cupertino Municipal Code, Section 9.18. I understand my plans shall be used as public records. c Date d Signature -�- Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 - - - CUPERTIND (408) 777-3228 • FAX (408) 777-3333 • buildime-cupefto.ong �- ❑ NEW CONSTRUCTION ❑ ADDITION E ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 1 O' 2- -5 W& l 2J a) APN # -� ;1 x , OWNER NAME o14W tVoftj G PHONE 4115--,57? 15-^r j? 72A E-MAILA J /) e- STREETADDRESS�O,�Z t•_ o laQ I C STA ZIP /. t'5�1 FAXZS ��a fylkff CONTACT NAME A� f �/� (f s "• L PHONE �� E -N AM STREET ADDRESS a z N. wv Iry R ARCHITECT/ENGINEER NAME �d CITY, STATE ZII' CA 5-10 FAX 7 ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMES I LICENSE NUMBER E-MAIL LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME �d LICENSE NUMBER BUS. LIC # CONPANYNAME Tf)A E-MAIL FAX STREET ADDRESS � kfor ! Z� l CITY, STATE ZIP tl A •, « PHONE t (i DESCRIPTION OF WORK T/ 4 _ _L M // / dt I� nI At �n A -u EX TING USE PROPOSED =TG NE lJFh l9RT` IAN0ffflo)� �wftcmvul� CONII( TYPE I #STO 7 DEMO I TOTAL Bldg,4pp_2011. doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ,10123 wolfe rd. suite 2100 DATE: FLR AREA s.f. REVIEWED BY: bob s. JimADDRESS: APN: ' (p 0 U �� BP#: II-B,111-B,IV,V-B "VALUATION: 1$82,500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: I Permit Fee: PENTAMATION 1 B TI I PERMIT TYPE: WORK business space, includes t -bar, mech electplumb, restroom upgrade, new partitions. SCOPE [!Lcommercial PME Unit Fee: OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. FEE PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,111-B,IV,V-B 5,221 $2,177.60 . 1 TIPLNCK $3,981.88 IBTIINSP $0.00 Permit Fee: $3,981.88 Suppl. Insp. Feer Reg. OOT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 5,221 $2,177.60 $3,981.88 $0.00 TIC?, Ch'yet: e.')Ihre' 1'rf dffFt: F't F.�fi. NOTE: These fees are haced an the nrelitninary informatinn availahle and aro nnly an octimato_ Cantart the Dont Mr addn'1 infn_ FEE ITEMS (hee Resolution 09-051 E '. 7%1110,) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,177.60 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $3,981.88 Suppl. Insp. Feer Reg. OOT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: ® Yes (D No $0.00 Q 0 Work Without Permit? ® Yes Q No $0.00 Plaming Fee: $0.00 Select a Non -Residential Q Building or Structure 0 -r . , . , 7 7 i. £ Lt1'L, 1 .i,� ��x:Zdtf7c,'is`,.{L'fi1Z .�"� £'t.'<S. Strong Motion Fee: IBSEISMICO $17.33 Select an Administrative Item Bldp, Stds Commission Fee: IBCBSC $4.00 �,,3 3,33,3,,,,,, , �'T(i�TALS TIM<.a, $6,180.81 $0.00 TOTAL FEE: $6,180.81 Revised: 04/29/2011 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildina(a-_)cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS I 0I 13 b.Wolk qo (nTc Fi C (l�pl APN BP# OWNER NAME OWNER ADDRESS p123 . WO/gjalQ DESCRIPTION OF WORK: We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) K1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 6W2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. W9. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 66-1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. l004-1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer under state and federal law. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. L� understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. nderstand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for NyOn&an cialor personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForin 2010"doc revised 04114/10 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contraactors.66 A. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that am the party legally and financially responsible for proposed construction activity at the site address listed above. lb11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide all applicable laws and requirements that govern Owner -Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuin!Jythe permit. Note: A copy of the property owner's driver's license, form notarization, or other verification accep to city may be required to be presented when the permit is issued to verifythe property owner's si na Property Owner's Signature: Dat --------------------------------------------------------------------------------------------------------------------------------------------- (NOTE. The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. AAA Property Owner's Signature: / / r l Date: Owne7BuilderForn1 2010.doc revised 04114110 14 UNREASONABLE HARDSHIP EXEMPTION FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL CUPERTIN O 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingt7a cupertino.org tFnr Tenant Imnrovements where the Cost of Construction does not exceed $128.410.90) SITE ADDRESS !0/23 0, Wot - goad, 574Ae. 200 APNBP# Sib - zo —©q7 t 1060053 CITY 1%W ZIP q5'o t 4 TOTAL CO,,NST.,R�UCTIO-N7-COST A $ .1...... DESCRIPTION OF WORK: ketnDd�e�l. PteIL:5 fG%ibtr iv(, /D 7Z7i/`da- k, !ILvt 2 aae,04 The following is a list of costs to provide access features in order to comply 100% with the current State Title -24 Disable Access Standards. (All .. f. +. he A ..... -+-1 by orh sol hiric nr ^ff c info fin -c f.ri by the R. dMi— nffirial 1 Accessible Features Complies with If not, list required upgrades in order for Cost to make feature o !/ °/" current standards? features to fully comply? fully accessible? 1. Path of travel to accessible entrance. azzP-,S s; b % a,►.eSi L of nd� TOTAL COST OF PROPOSED UPGRADE $ h?, d © O 2. Cost of providing a primary entrance. (Including but %mum expend required) 2 •75 not limited to, thresholds, landings, door hardware, $ max. door pull, etc. 3. Cost of providing the primary path of travel to the - specific area of alteration, structural repair, or $ addition. 4. Cost of providing accessible restroom facilities. ` A V $ l b 000 , 5. Cost of providing an accessible drinking fountain. (If,� 1 A .__. $ required or if a drinking fountain is provided.) (► 6. Cost of providing accessible public telephones (if f $ --------- ---—provided) provided) u V 7. Cost of providing other accessible features, including -rking, , .$ i� v $ ODO but not limited totorage, alarms etc. P TOTAL COST OF ACCESS FEATURES (B): $ , , oo e' Has the same tenant performed work in the_ same tenants ace within the last three ears Calculate (B / A) x 100% o !/ °/" Description of access features to be provided: 1) 2 Ga e.4 5 i%k /ze,, i'Vnros w'A 2 AQA-)-o, lets 4"J azzP-,S s; b % a,►.eSi L of nd� TOTAL COST OF PROPOSED UPGRADE $i � ],PERCENTAGE._( %mum expend required) 2 •75 ARCHITECT OR ENGIN]fE,E�R� Oj,F� /RECORD INFORMATION: I certify that the above . rmation isis true and cor ect. Name (print): �d '1 91 Signature: — Date: Firm address: Title: Phone: ---------------------------------------------- __----------- .---- FOR DEPARTMENT USE ONLY---------------��--------------------------------------------------------------- ❑ The above named project has been denied an unreasonable hardship exemption under 2010 CBC Section 1134B.2.1. The above named project has been granted an unreasonable hardship exemption from the requirements of the State of California CCR -Title 24 (Regulation for the Accommodation of the Disabled) pursuant to 2010 CBC Section 11346.2.1. COMMENTS: Building Official Designee (print): At, t -M ✓ t) -V 6'/ "( Signature: Date: Hard. hipExemptionForm 2011.doc revised 02/25/11 F- 16