15060074I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 19505 STEVENS CREEK BLVD STE 102 CONSTRUCTIONCONTRACTOR:
ACOR HD & MASON I PERMIT NO: 15060074 I
I OWNER'S NAME:
SAN JOSE, CA 95121 PHONE NO: (408) 223-5600
D LICENSED CONTRACTOR'S DDE�C1LARATIO/N'J
License Class_ Lie. #l%"� �v
Contractor4 Date 5
I hereby affirm that I am licensed under the provisions of Chapter 9
(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:
t. 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.
2. 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 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and
Code, Sect�io^n 9.18.
Signature DateJPf
® OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. 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)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. 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.
2. 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 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
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 forthwith comply with such provisions or this permit shall be deemed
revoked.
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
indemnify 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 with
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
Date
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
TI SUITE 102 -THE TEA ZONE & FRUIT BAR 1175 SQFT
Revision #1 - Accessible Path of travel clarification, Door opening into kitchen, Lighting
Layout, Floor Drain Location
Sq. Ft Floor Area: Valuation: $45000
APN Number: 31649009.102 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: 2/V' —Date: 7 `
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
I have read the hazardous materials requirements under Chapter 6.95 of the
California H alth & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance vOith the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(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 I will
maintain comptian h theCupertino Municipal Code, Chapter 9.12 and the
Health & Safetyode, ections 25505, 25533, and 25534.
Date;
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is. a construction lending agency for the performance of work'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 Professional
CITY OF CUPERTINO 10*43
FEE ESTIMATOR - BUILDING DIVISION
. ADDRESS: 19505 Stevens Crk Blvd Ste#102 DATE: 09/2312015 REVIEWED BY: PAUL
APN: 316 49 009.102 ---FB—P#: *VALUATION: Iso
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial BuildingPENTAMATION
USE: PERMIT TYPE: 1 GENCOM
WORK Revision #1 - Accessible Path of travel clarification Door opening into kitchen Lighting Layout, Floor
SCOPE Drain Location
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
ne mz r_ z -a •z ..v..
------ !'nwinri ih0 I)Pnt for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/73)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes (j) No
$0.00
= hours Plan Check, Hourly
$143.00 ISTPLNCK
Suppl. PC Fee: Q Reg. 0 OT0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
T_
Construction Tax.
F_T_
Administrative Fee:
0
Work Without Permit? 0 Yes' (E) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
Trowel Docurnernation fees:
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SBTC)°FAES`
$0.001
$143.00$143.00
r"tMbuu. V I /VGL6.v i a
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19505 STEVENS CREEK BLVD STE 102
CONTRACTOR: TBD - TO BE
PERMIT NO: 15060074
DETERMINED
OWNER'S NAME:
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL F1 COMMERCIAL
License Class� 99y 7 qC?
TI SUITE 102-THE TEA ZONE & FRUIT BAR 1175 SQFT
I:ic. #
es�
Contractor_ � ,%�.�9nJ(--> Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(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: $45000
erformance of the work for which this permit is issued.
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: 31649009.102
Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
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
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify 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
Issued by:��o�/�O �7� Date: 4!�
with all n -poi t source regutali he Cupertino Municipal Code, Section
7spe
9.18.
Signatur Date .
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.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
Signature of Applicant: Date: "
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code,' ns 1 33, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
6--4/
permit is issued.
Owner or authorized agent
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
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FE -0 FEE ESTIMATOR - BUILDING DIVISION
imADDRESS:
19505 Stevens Creek Blvd #102
DATE: 0611012015
REVIEWED BY: PAUL
PC FEE ID
APN: 316 49 009
BP#:
'VALUATION: 1$45,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE:
$2,144.34
PENTAMATION 113 TI
PERMIT TYPE:
WORK
TI - The Tea Zone & Fruit Bar Ste #102 - 11,75 S.f.
SCOPE
PME Plan Check:
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
B (Tenant Improvements)
II-B,111-B,IV,V-B
1,175
$2,144.34
IBTIPLNCK
$1,203.24
IBTIINSP
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,203.24
Suppl. Insp. Fee:Q Reg.
Q OT
10701
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
TOTALS:
1,175
$2,144.34
$1,203.24
MECH,$OJURLY 0 Yes' E) No PLUMB, HOURLY a Yes Q No ' LLEC, HOURLY Q Yes Q No
ED'Li=F
. l ;L't ) .'77r. � dttr
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
Dictrirt ote )_ Thoso foot aro hasod an tho nroliminary infnrmatian availahlo and are nnlv an Pvimate_ Cantart tho Dent tar addn'l inln_
FEE ITEMS (Fee Resolution 11-053 Eft 7,/f 1!13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,144.34
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (DReg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,203.24
Suppl. Insp. Fee:Q Reg.
Q OT
10701
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
E)
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
�- y
Strong Motion Fee:
1BSEISMICO
$12.60
Select an Administrative Item
Bl y, Stds Commission Fee: 1BCBSC
$2.00
4
SUBTOTALS:
$3,362.18
$0.00
TOTAL FEE:
1 $3,362.18
Revised: 05/07/2015