15040161CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10520 S DE ANZA BLVD
CONTRACTOR: 5
PERMIT NO: 15040161
,4L.4/r'to L1_ f T N�
OWNER'S NAME: HARMAN-MANAGERS INVESTMENT INC
�fO /%%dlV�i/ylE/�T Oy A
DATE ISSUED: 04/22/2015
OWNER'S PHONE: 6509415681
gv_51
PHONE NO:9�
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E]
KFC - INSTALLATION OF (1) NEW CIRCUIT TO COOK
License Class Lic. # a� S �J
LINE
P\dm L.1. a 22 , t 5�
FOR AN EXISTING OVEN (50 AMP-220 VOLT).
Contractor p G h'* \ nS 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: $3500
performance 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
APN Number: 36939017.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
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
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
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
��Q �/ �� 7
Issued by: �if?Date:
granting of this permit. Additionally, the applicant understands and will comply
, f� ��•/�l
with all non-point source regulations per the Cupertino Municipal Code, Section
9 18.
/t 'L'2 S
RE-ROOFS:
Signature �� \ Date 4'
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
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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. I 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, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:
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
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
918.
Signature Date
CUPERTINO
) 5LO 2-10 / k) /
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(cDcugertino.org
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
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ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD or DUPLEX ❑ MULTI -FAMILY
PROJECT IN WILDLAND ❑ YES
PROJECT IN ❑ YES
IS THE BLDG AN ❑YES
BUILDING: COMMERCIAL
URBAN INTERFACE AREA 100FLOOD
ZONE NO
EICHLER HOME? NO
DESCRIPTION OF WORK n C 1 Y C l.C,-1 ' V v
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TOTAL VALUATION: ;A:5 s
By my signature below, I certify to each of the following: I am the property owner or authorized agent to acrolr& prop er's behalf. I have read Is
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 to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Date: '-�• a'
Signature of Applicant/Agent:
SUPPLEMENTAL INFORMATION REQUIRED ", _ A oFcE usE'oivLY� 2 y
� OYER TH�COiJNTER �
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MEPMiscApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
Fm-� FEE ESTIMATOR — BUILDING DIVISION
APPLIANCE / EQUIP TYPE
10520 S DE ANZA BLVD
DATE: 04/22/2015
REVIEWED BY: SEAN
JimADDRESS:
APN:
BP#:
"`VALUATION: 1$3,500
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: Commercial Building
#
PENTAMATION
PERMIT TYPE: 1 CEAP A
WORK
INSTALLATION OF 1 NEW CIRCUIT TO COOK LINE FOR AN EXISTING OVEN 50 AMP -220
SCOPE I
VOLT).
APPLIANCE / EQUIP TYPE
FEE ID
Elec. Plan Check 0.0 hrs $0.00
QTY
UNITS
BP FEES
Elec. Permit Fee: ]EPERMIT
Special Circuits
1BREMMISC
Other Elea Insp. 0.0 hrs $48.00
1
#
$143
f'etrniC .F'ec>:
si pp[ Insp I'ee
PME Unit Fee:
$143.00
PME Permit Fee:
$48.00
Construction 7GJ#:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? ® Yes (E) No
$0.00
TOTALS:
A
;7il > 5g:
$143.00
Strong Motion. Fee: IBSEISMICO
S, .,ug ✓n�� ups S� _`3,�����
{ty C
NS,W:1
Plumb. Pkin (.'heck
Elec. Plan Check 0.0 hrs $0.00
Nh,c;h. Man Check
FLier.,h. Peralit Fee:
Plumb. Permit Fee:
Elec. Permit Fee: ]EPERMIT
(.Oilier Afcch. Irtsp.
father Plumb Insp.
Other Elea Insp. 0.0 hrs $48.00
it ech. Insp. Fee:
Plumb. Resp. Fee:
I lec. 1nrp. 1 ee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Lire, Sanitary Sewer District, School
Mcfrirt air ) Thoco foot aro hacod nn tho nroliminary information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13)
FEE
QTY/FEE
MISC ITEMS
P16jr/ (:"heck 1{'ee:
suppl—p(.' P'ee
PME Plan Check:
$0.00
f'etrniC .F'ec>:
si pp[ Insp I'ee
PME Unit Fee:
$143.00
PME Permit Fee:
$48.00
Construction 7GJ#:
Administrative Fee: ]ADMIN
$45.00
Work Without Permit? ® Yes (E) No
$0.00
Advanced Planning fees:
A
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion. Fee: IBSEISMICO
$0.98
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
rr NW111,p a
$285.98
$0.00
Revised: 04/01/2015
Z
County of Santa Clara
Department of Environmental Health
Consumer Protection Division
1555 Berger Drive, Suite 300
San Jose, CA 95112-2716
(408)918-3400 FAX (408)258-5891
www.EHinfo.org
August 11, 2015
KFC
Attention: Ron Patterson
199 First Street, #212
Los Altos, CA 94022
Dear Mr. Patterson:
PROJECT NUMBER: SROB47463
PROJECT NAME: KFC
PROJECT ADDRESS: 10520 S DE ANZA BLVD
CUPERTINO
The drawings for the above noted remodeling project have been reviewed and approved by this
department, subject to the following conditions:
■ This approval is for the new pack line in the kitchen.
All food service equipment must be certified or classified by an American National Standards
Institute (ANSI) accredited certification program, e.g. NSF, ETL Sanitation, UL Sanitation, UL
EPH.
® The hand sinks, food preparation sink, 3 -compartment sink, and janitorial sink are to be verified
during inspections. Additional requirements to correct deficiencies may apply. All existing
equipment, facilities or finishes that will remain shall be evaluated and approved on a case-by-
case basis during on-site construction inspections. Equipment or finishes not found to be in
compliance will not be accepted.
if Contact our office for review and approval for any changes to the approved drawings, including
structural and/or equipment changes.
This approval shall expire by limitation and will become null and void if the construction, reconstruction,
alteration, or other work authorized by this approval is not commenced within 180 days from the date of
approval.
Please retain one copy of the approved drawings on the job site. A FOOD FACILITY CONSTRUCTION
CARD has been attached to the job copy and must be posted with the other building permits. Present at
least two (2) copies of the drawings to your local building official for the required permit application and
approval. Any change to the drawings as a result of reviews by other jurisdictions must be
brought to the attention of this department as soon as possible to avoid construction delays.
Please be advised that you are responsible to contact this office to arrange a construction inspection
before rough plumbing signoff, installation of equipment, and upon completion of the project. You will
also be asked to submit a mechanical exhaust system performance test, if such a system is
present, before we can finalize the project. The original submittal fee(s) includes up to two (2)
inspections. Additional fees may apply to any further inspections or site visits. In the event the project is
not ready for a scheduled inspection, please provide at least 24 hours advance notice to avoid additional
charges for canceled inspections/missed appointments. The Final Inspection for the project cannot
take place until the balance for all Plan Check -related work is PAID IN FULL. Failure to meet
this requirement will result in the cancellation of the Final Inspection. Please note: Rescheduling will be
subject to availability.
All food -handlers are required to obtain a food handler card within thirty (30) days of hire (with certain
exceptions). Contact this Department for more information.
Board of Supervisors: Cindy Chavez, Mike Wasserman, Dave Cortese, Ken Yeager, S. Joseph Simitian
County Executive: Jeffrey V. Smith
If you have any further questions or would like to call for an inspection appointment, please contact the
Department at (408) 918-3400, between 8:00 a.m. and 5:00 p.m., Monday through Friday.
Very truly yours,
Sally Lee, REHS
Senior Environmental Health Specialist
Plan Review and Construction Unit
Enclosure
cc: City of Cupertino Building Department
Owner
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10520 S DE ANZA BLVD CONTRACTOR:5 PERMIT NO: 15040161
,4L.4/r'to L1_ f T N�
OWNER'S NAME: HARMAN-MANAGERS INVESTMENT INC �fO /j�JdlV�i/ylE/�T cry A DATE ISSUED:04/22/2015
OWNER'S PHONE: 6509415681 �n/� �`,q qy_51PHONE NO:9�
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E]
-� KFC-INSTALLATION OF(1)NEW CIRCUIT TO COOK
License Class Lic.# 1 a n�S�j LINE
Contractor P\dm p L.1.G 1r1—*\nS Date
a 22, t 5� FOR AN EXISTING OVEN(50 AMP-220 VOLT).
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
erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3500
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 APN Number:36939017.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
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, �� 7
costs,and expenses which may accrue against said City in consequence of the ��Q�/ ��•/�l�if? Date:
granting of this permit. Additionally,the applicant understands and will comply Issued by: , f �
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
/t 'L'2 S RE-ROOFS:
Signature �� \ Date 4' 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. I 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,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:
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 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
918.
Signature Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISC
(408) 777-3228• FAX(408)777-3333•building(c�cugertino.org
CUPERTINO
❑PLUMBING ❑MECHANICAL I&tLECMCAL ❑MISCELLANEOUS
[PROJECT ADDRESS 1 0�e 9D e A h l v d APN#NA ra.yl r 1lana �me✓L P ofO w LE-MAIL
TjLE T DRESS s r ITY,STATE ZIP (� ^2-
FAX
FA
CONTACT NAMEr •��/ ONE f i �� E-MAIL
STREET ADDRESS i C STATE,ZIP E7 f F
❑ OWNER ❑ OWNER-BUII-DER El OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER 11 TENANT
CTOR NAME , ft Fgg LICENSE TYPE B�J�S.LIC#
C PANYNAME E ��L 01 MUi I r„�L n _` FAX
STRE T DRES C STATE,ZIP �l l� �`1 r�' �!J '
n u ert4 A
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WHALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: IIACOMMERCLA.L URBAN INTERFACE AREA WOFLOOD ZONE NO EICHLER HOME? NO
DESCRIPTION OF WORK n C 1 Y C l.C, ' V v
(/� X ( n ° SO 2,20 tic)nr
TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to ac a prop er's behalf. I have read Is
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 to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: ' a'
SUPPLEMENTAL INFORMATION REQUIRED ", _ A oFcE usE'oivLY�2 y
� OYER THE-COUNTER �
F EXPRESSfi
A�
S"-0V 1110'1i
TANDARD k
rz
MEPMiscApp_201 1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10520 S DE ANZA BLVD DATE: 04/22/2015 REVIEWED BY: SEAN
MIAPN: I BP#: "`VALUATION: 1$3,500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/Repair
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1 CEAP
WORK INSTALLATION OF 1 NEW CIRCUIT TO COOK LINE FOR AN EXISTING OVEN 50 AMP-220
SCOPE I VOLT).
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Special Circuits 1BREMMISC 1 # $143
TOTALS: ;7il $143.00
Nh,c;h, Man Check Plumb.Pkin(.'heck Elec.Plan Check 0.0 hrs $0.00
FL1er.,h. Pereslit Fee: Plumb.Permit Fee: Elec.Permit Fee: ]EPERMIT
(.Oilier Afcch. Irtsp. other Plumb Insp. Other Elea Insp. 0.0 hrs $4$.00
1l ech. Insp. Fee: flat$. Resp. Fee: I lec. 1nr�. 1 ee:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). Theseees are based on the relimina information available and are onlyan estimate. Contact the Det or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
1'I6rn(:"heck I"ee:
sup/:l-p(.1 P'ee
PME Plan Check: $0.00
f'errniC.F'ec>:
si pp[ Insp I'ee
PME Unit Fee: $143.00
PME Permit Fee: $48.00
Construction 7crx:
Administrative Fee: ]ADMIN $45.00
Work Without Permit? ®Yes (E) No $0.00
Advanced Planning 1 ees:
Travel Documentation Fee: ITRAVDOC $48.00 A
Strong Motion.Fee: IBSEISMICO $0.98 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
rr NW111, p a $285.98 $0.00
Revised: 04/01/2015