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11080106 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20520 STEVENS CREEK BLVD CONTRACTOR:WELLS CONSTRUCTION PERMIT NO: 11080106 INC. OWNER'S NAME: MARDESICH CO CROSSROADS LLC 10648 INDUSTRIAL AVE DATE ISSUED:09/27/2011 OWNER'S PHONE: 4082553042 ROSEVILLE,CA 95678 PHONE NO:(916)788-4480 LICENSED CONTRACTOR'S DECLARATIONr r Q BUILDING PERMIT INFO: BLDG ELECT PLUMB License ClassF Lic.# (�! 1 G�5 r r MECH RESIDENTIAL COMMERCIAL Contractor ate I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:STARBUCK'S-COMM T.I(1,124SQFT)NON-STRUCTURAL- (commencing with Section 7000)of Division 3 of the Business&Professions NEW Code and that my license is in full force and effect. PLUMBING,LIGHTING,FLOORING&CASEWORK 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. Sq.Ft Floor Area: Valuation:$100000 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:35908018.20520 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN DAYS OF PERMIT ISSUANCE OR with all non-point source re ulations per the Cupertino Municipal Code,Section 180 DA OM LAST CALLED INSPECTION. 9.18. TIf } /� /�r� ' Date: Signature Date Issued by: , is f � r ❑ OWNER-BUILDER DECLARATION i I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 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. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. 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. 0 �, for ed a — Dater" 1 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit,Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional 11 4. CONSTRUCTION PERMIT APPLICATION 12 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 i CUPERTINO (408)777-3228• FAX(408)777-3333•bLllldinq(CbCUpertlno.orq ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS -�/� APN# !f - Z0 d o GJ� j CRf�l3l� �UR� ` �/ l J <a ed .(f' ` L OWNER NAME PHONE E-MAIL nl�c� mr�zr�eS cl{ 4 c 56. 255. s(A2 STREETADDRESS CITY, STATE,ZIP FAX �1201b cUP6(211x)o 6p� 9504 CONTACT 5o4 CONTACT NAME PHONE E-MAIL }32znvLCXZI�Iv ACCP C��3J (Z14, 61 .2I45 brIcAn. )6r,� w U Hers ,cam STREET ADDRESSCITY,STATE,ZIP FAX 700'�f)ZNX)), f?�UO C�YJ�l.1/� M 4'�0�177- ❑OWNER ❑ OWNER-BUILDER OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT LSI ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME r N 6 2O 2 ^ LICENSE NI MPP- LICENSE TYPE BUS.LIC# COMPANY NAME uj �J�•J E-MA11 - FAX STREET ADDRESS76J' --7- C)Y J�� Ute/ CI'1'�' cTnTa ern PHONE ARCHITECT/ENGINEER NAME I✓ J LICENSE NUMBER I BUS.LIC# ��tJ(Y12bUJC�c� COMPANY NAME E-MAIL CiVNI�"CL FAx STREET ADDRESS CITY,STATE,ZIP U PHONE DESCRIPTION OF WORK G�-'�tX92RL 213r�'100(�l� �� S�A2�)G5 "1ft1�C�0v�Z RP-�-�,� "40 U&H-1 -Zk� CHAW6I EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES OFFICE USE ONLY .l-il � AIILI Rt�� v 1J I OCC. TYPE DESCRIPTION S .FT. VALUATION NEW EMO TOTAL BAREAG I�"-I AREA FLOOR DAREA NETAREA I Z� VIN BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA 1 I I �� PORCH EA DECK A,I2EA TOTAL DEgK//,PORCH AREA GARAGE AREA:El DETACH _ Q� "C A) ❑ ATTACH #DWELLING", TS: ISA SECOND UNIT ❑YIS SECOND STORY ❑YES BEING ADDED? NO ADDITION? NO ,,✓r'''�s PRF.-APPLICATION ❑ YES IF YES,PROVIDE COPY OF PI-A,N11 WSNAME:: RECEIVED BY: ,� - ( -T TAL VALUATION: PIANI NNG APPL# UCO PLAN�NINGAPPROVALI.ETTER By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating buildi construction. I au t�hhorize r presentatives of Cupertino to enter the above-identified property for inspection proposes. WO P(2IfLY4L'j Signature ofApplicant/Aget X710WZOOL A-UT U]J A' Date: 0(X4 201 SUPPLEME�Tt NF6RMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER -®nuiiDINGP AN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. CRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT ' Copy of Planning Approval Letter or Meeting with Planning prior to ❑ mAjoR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 Ldoc revised 03116111 t I i Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT 1 N® Fax: 408-777-3333 CONTRACTOR SUBCONTRACTOR LIST JOB ADDRESS: .00, revp-Q cook-- PERMIT# f OWNER'S NAME: PHONE# (� GENERAL CONTRACTOR: , �� . �; � BUSINESS LICENSE# ADDRESS: t i vSrrk-j 1-�j ' CITY/ZIPCODE: -Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum/Wood Glass/ Glazing Heating I Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ® I i Owner/Contractor Signature Date