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10040164CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20700 STEVENS CREEK BLVD CONTRACTOR: DILANTHI PERERA PERMIT NO: 10040164 OWNER'S NAME: DILANTHI PERERA 20700 STEVENS CREEK BLVD DATE ISSUED: 04/27/2010 H'ER'S PHONE: 4088499904 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL REFRIGERATOR TO EXISTING OUTLETS (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my 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 Sq. Ft Floor Area: Valuation: $5000 performance of the work for which this permit is issued. 1 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. APN Number: 35908020.20700 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities, judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section _ ,f� � .//` Issued by� lDate: � 9.18. Signature Date RE -ROOFS: [Vi OWNER -BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self -insure for Worker's California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain Compensation, as provided for by Section 3700 of the Labor Code, for the compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & performance of the work for which this permit is issued. Safety Code, Section 25532(a) should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance, as provided for by Additionally, should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code, for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the permit is issued. p Health & Safety Code, Sections 25505, 25533, and 25534. I certify 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 Owner ot ri d agent: Compensation laws of California. If, after making this certificate of exemption, I Date: Cl 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued (Sec. 3097, Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes. (We) agree to save > >nify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply I understand my plans shall be used as public records. with all non-po our a regulations per the Cupertino Municipal Code, Section 9.18. Licensed Professional Signature Date � %a 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35908020.20700 DATE ISSUED.......: 04/27/2010 RECEIPT #......... BS000010278 REFERENCE ID # ...: 10040164 OPERATOR: patg COPY # : 1 SITE ADDRESS .....: 20700 STEVENS CREEK BLVD SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER DILANTHI PERERA ADDRESS 20700 STEVENS CREEK BLVD CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: DILANTHI PERERA CONTRACTOR LIC # *OWNER* COMPANY DILANTHI PERERA ADDRESS 20700 STEVENS CREEK BLVD CITY/STATE/ZIP ...: CUPERTINO, CA 95014 TELEPHONE ........: FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC -------------------- NEW BAL ----------------------- 1BCBSC VALUATION ---------- 5,000.00 -------------------- 1.00 0.00 1.00 0.00 1BSEISMICO VALUATION 5,000.00 1.05 0.00 1.05 0.00 1EPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1ERESAPPL NO OF APPLIAN 1.00 21.00 0.00 21.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- ---------- 107.05 0.00 107.05 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- CHECK 107.05 -------------------- #1099 --------------- TOTAL RECEIPT 107.05 Assessors Parcel Number: -01Z-4) Name of business. Jl.k�6.12 �- ?a s15 1,3V S:- � Pro'ect address D700 Contact person. Phone. 40` Fax. Current use of space. L � --4 Proposed use. J Building construction type. Occupancy Group(s) 15 Occupancy Load. 10 v Al V1 O -)quare footage of remodeled area. Is the building equipped with: Fire sprinkles? CY - N; Fire alarm system? N Number of floors in the building? I On what floor(s) is work being done? Brief description of work. L11� - � _ - • �iE- BSc. iS ti--l�a CZ '�c�.Zo✓l Code editions: 2008 CBC CV- N)2008 CFC (Y - N)2008 CMC (Y- N) 2008 CPC (Y - N)2008 NEC <ff:-)N) Effective 1/1/08 Are there any chemicals/hazardous materials to �p �1%p4 at site? oF Y QN If above answer is yes, provide a list �fdNCEs If job is involves food service, provide 3 &'tea d% sets far health Department review. SIGNED This set of plans and Specifications MUST be kept on the lob at all times and it is unlawful to make any changes or alterations on same without written permission from the Building Department City of Cu rtino. The stamping of this plan rind specifications SHALL NOT be hely to permit or to be an approval of the violation of any provisions of any City Ordinance or State Law. Commercial Plan Review Process Work BookPage -10- revised 1/1/08 FE pE RAL Item SERIES '90 REFRIGERATED BAKERY CASE MODEL SNR-48SC SNR-59SC ,SNR-77SC Series '90. The ultimate merchandiser with advanced styling for maximum visual appeal. Cases are available in lengths of 48" 59", and 77". Designed for continuous case line-ups. STANDARD FEATURES - Adjustable white cantilevered wire shelves. Shelves are adjustable up and down, and can also be tilted. - Lift -up pneumatic, cylinder -assisted double -curve tempered front glass. - Four point leveling system. - Removable sliding rear doors, shelf lights, shelf supports and shelves. - Glass ends and rear doors. Rear doors are sloped for product access. - Octron top light and shelf lights. Lights are shielded and independently wired. - All welded base construction with a choice of six standard laminates on base. Other finishes optional. - Easily accessible control panel with main power switch, light switch, digital thermometer, and adjustable temperature control. - Neutral beige acrylic PVC trim. Trim does not show scratches and is very easy to clean. - Double bend tempered frwnt glass reduces glare from outside lighting. - Case height is only 48" high allowing better interaction between the customer and the sales clerk. - White display deck. - Condensate evaporator for a totally self-contained system. - Average case temperature of 38° to 40° F is maintained without condensation on the front glass. - Over -sized coil and low velocity fan system maintains high humidity and product freshness. - Pull out condensing unit for quick and easy service. - R 34A Refrigerant. - UL Safety and UL Sanitation Listed. SERIES '90 REFRIGEItATED BAKERY CASE OPTIONtkL ACCESSORIES: * Package Shelf * Light Below Package Shelf * Glass Shelves * Rear Wrapping Board * Reflective Rear Doors * Cord & Plug (Self -Contained * Special Base Finish Models Only) * Remote Refrigeration * Black, Chrome, or Gold Wire Shelves * Casters (Self -Contained* Black Interior Models Only) * Chocolate Case Modification * Front Glass & Rear * To Service Shelf ELECTRICAL Top CONNECTION Door Locks BOX * Legs ' * Special Trim 0 °1 * Reflective Ends 4 (18" x 26") 8 (12" x 18") tI PLAN VIEW I 18' SHELF T� llr�22' SHELF T-11 3/4 213/4�' �+--37 3/4 SIDE VIEW n Ts I, Irl 17th ArrillAlC ,, 26' SHELF x131 1 19 1/2 8 1/8 OPTIONAL FRONT PACKAGE SHELF 48 1/2 L FRONT VIEW 7 ,E 3 SANITATION sirir OU`- Cases are designed to operate in a maximum environment of 750 ambient and 55% relative humidity. U` -Due to continuing engineering improvements, specifications are subject to change without notice. Look to Federal for Innovative Merchandising Federal Industries A Standex Company 215 Federal Avenue �E�ERAL Belleville WI 53508-0290 —•.�— Phone: 800-356-4206 Fax: 608-424-3234 Email: geninfo@federalind.com Web Site: www.federalind.com I/03 SN9601 Dimensions Shipping Capacity Self -Contained Remote Model L W H Weight (lbs) (Bakery Pans) 120/60/1 120/60/1 SNR-48SC 48 1/4" x 37 3/4" x 48 1/2" 750 4 (18" x 26") 8 (12" x 18") 1/2 HP - 12 AMPS 13.2 AMPS 2 ( 9" x 26") SNR-59SC 59 1/4" x 37 3/4" x 48 1/2" 825 6 (18" x 26") 8 (12" x 18") 1/2 HP - 12 AMPS 13.2 AMPS SNR-77SC 77 1/4" x 37 3/4" x 48 1/2" 1,050 8 (18" x 26")12 (12" x 18") 3/4 HP - 16 AMPS 17.3 AMPS 3 SANITATION sirir OU`- Cases are designed to operate in a maximum environment of 750 ambient and 55% relative humidity. U` -Due to continuing engineering improvements, specifications are subject to change without notice. Look to Federal for Innovative Merchandising Federal Industries A Standex Company 215 Federal Avenue �E�ERAL Belleville WI 53508-0290 —•.�— Phone: 800-356-4206 Fax: 608-424-3234 Email: geninfo@federalind.com Web Site: www.federalind.com I/03 SN9601 OWNER -BUILDER DISCLOSURE FORM C�LJPEEr1t"� rN[O =1.r 4 8 ' 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 '1 0-706 Skhe" S (lel OWNER NAME I f I.., Qelv� OWNER ADDRESS -lob e C�1vCl DESCRIPTION OF WORK: ,1� S fid{ ` V� ' 1 '( fv1 �' I s �1/',(��e� eJec Y i Lti 0 ©vii le 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.) X1. 1 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. __�;k_2. 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. 3. 1 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. VJ_4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. -&Ir-5. I 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. �6,,l 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. �7. I 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 i performed under contract with a licensed general building Contractor. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. 01171.erBuilde7"FO7"r/1_2010.doc revised 04/12/10 "�_ 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.csib.ca.gov for more information about licensed contractors. �✓ 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by 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 responsiblefor issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification' acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature.' Signature of property owner: Date: AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF (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). 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 I 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 owner's driver's license, form notarization, or other verification acceptable to the agencyrequired to be presented when the permit is issued to verify the property owner's signature. � � , Property Owner's Signature: G Date: "► �0 l) Own.erBuilderForm 2010. doe revised 04/12/10 CITY OF CUPERTINO In of GENERAL BUILDING APPLICATION CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1WINMEWSTR New Window -structural shear B wall/masonry (includes plan ck fee) 1EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly -stand alone / 1BCBSC Cal Bldg Standards Commission Fee B ALL EP ES 1BSEISMICRRMIT I Seismic Residential g 1BSEISMICO Seismic Commercial B 1T VDOC Travel & Documentation B 1BUSLIC Business License B / �� SAPS' / 5 of 5