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15030019
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10477 S DE ANZA BLVD CUPERTINO CA 95014 (359 17 019) CONTRACTOR: PERMIT NO: 15030019 1689 VISTAGRAND DR SAN LEANDRO, CA 94577 OWNER'S NAME: BDC HAYWARD L.P. DATE ISSUED: 06/11/2015 OWNER'S PHONE: (925) 588-2225 PHONE NO: None LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class 13 Lie. #915513 Contractor Date 05-31-2018 —BLDG —ELECT — PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing — MECH — RESIDENTIAL — COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury one of the following two declarations: VERDE TEA HOUSE; SUITE A; COMM. T.I TO INCLUDE m. I have and will maintain a certificate of consent to self -insure for Worker's , INTERIOR EAPROVEMENTS 1448 SQ FT ;REV #1 RELOCATE HAND SINK, REPLACE (1) 60 GAL WATER Compensation, as provided for by Section 3700 of the Labor Code, for the 'HEATER WITH (2) INSTANT WATER HEATERS_ ISSUED 'performance of the work for which this permit is issued. 10-7-2016 2.V 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 Sq. Ft Floor Area: Valuation: $187500.00 CERTIFICATION certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 35917 019 - 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. .Additionally, the applicant understands and will comply with all non -point WITHIN 180 DAYS OF PERMIT' ISSUANCE OR source regulation per the Cupertino Municipal Code, Section 9.18. x, 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 10/7/2016Issued by: D -w OWNER -BUILDER DECLARATION / �, Date: _. j ! - 2-0 r� tG' I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for inspection. sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature ofApplicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 10/7/2016 I hereby affirm under penalty of perjury one of the following three declarations:ALL m. 1 have and will. maintain a Certificate of Consent to self -insure for Worker's ROOF COVERINGS TO BE CLASS "A" OR BETTER Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is. issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I exemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Co ►s Z33Q3; 55 and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall " be deemed revoked. Owner or authorized ages -- -- APPLICANT CERTIFICATION Date: 10/7/2016 certify that I have read this application and state that the above information is CON TR TI01v' WINGAGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.18. 1 understand my plans shall be used as public records. Signature Date 10/7/2016 Licensed Professional CONSTRUCTION PERMIT APPLICATION .E COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISI 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 buildingCokupertino•ora 0 NE -1V CONSTRUCTION ❑ ADDITION ❑ .ALTERATION / TI ❑ REVISION /DEFERRED ORIGIN j ��" Bld,App_2011.doc revised 06121/11 - AL PERMIT R�IECT ESSp APN r 4� OL eu 14A ] A % j P E-? ZAIL t If�r c L� q � ST S , CT Y. STATE; Z FAX �f'U4 a C> 11 CONT CT N?' E I PH E-DrLAIL STREETADDRESS CITY, STATE, ZIP FAX ❑ OttTTER ❑ o)v,��-,R-DER ❑ OW1,'ERAGENT � CO1,7RACTOP ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGa\EER ❑ DEVELOPER ❑ TEN:4ATT CONTR CTOR N A4E LICE.' E NUMBER LIC TSE TYPE BUS. LIC r - r A PANY :q 4E 555 f j9 { E_n e a tox I FA p &A-61Cy)� Yom. / ! 4122211M P ADD S % LJ C9 4i� CITY TA ZIP %y ?� I PHONE t G v % .ARCHITECT/ENGINEER N.A15E I LICENSE N'UuBER BUS. LIC COMPAWI NAME E- 4AIL ` FAX -- I STREET ADDRESS CITY, STATE, ZIP PHONE � DESCRIPTION* OF WORK6e- a EXISTING USE - PROPOSED USE C01 STR 1TPE STORIES USE TYPE OCC. I SQ.FT. VALUATION (S) EXISTG NEW FLOOR DET,40 TOTAL — AREA AREA AREA NEI' AREA, BATHROOM KITCHEN OTHER REMODELAREA REb40DELAREA - REMODELAREA PORCH ;AREA DECI:AREA TOTAL .DECKTORCHAREA GARAGEAREA: [3 DETACH El ATTACH DV,ELLLNGLNTITS: ISASECOI DUNIT ❑YEs SECONDSTORY El YES _ BELNGADDED? E] -.NO ADDITION? EINO IS THEBLDG.4N ❑YES TOTAL VALUATION: PRE -APPLICATION El YES IF YES: PROVIDE COPY OF PLAAT`LNG.APPL= ❑.NO APPROVAL LETTER I EICHLERHOME? ❑NO 'r By my signature below, I certify to each ofthe following: I am the property owner or authorized aQen on the property owner's behalf. I have read this application and the information I have p -ovided 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 "aT754actie . uthorize representatives of Cupertino to enter the above -identified er[y for mspec ' npurposes. S i --nature of Applicant/Agent: —�� Date: SUPPLEMENTAL . TFORMATIONT REQUIRED „ PLANCAECKTYPE. WNW.ROLTING'SLIP, r ;; — New SFD or Multifamily dwellings: Apply for demolition permit for ❑ existing building(s). Demolition permit is required prior to issuance of building ER THE COUNTER BUILDIZG PL41� REY'IE�i permit for new building. ❑ `E�uEss � � � PLA �\LNGPL4n RE\ IE�i Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sT��D RD' 1] �tBLici;ORl.s ' ^Commercial form if any Hazardous Materials are being used as part of this project. ❑ Ls RGE CI FIRE DEPT Copy of Planning Approval Letter or hleeting with Planning prior to LAJDR ❑ submittal: of Building Permit application. SA�ITARISEYiERDI�TRICT x k Bld,App_2011.doc revised 06121/11 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION r,u� 40300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTIfVO (408) 777-3228 • FAX (408) 777-3333 • building@@cupertino.org 1 ❑ NEW CONSTRUCTION ❑ . ADDITION LI(4ALTERATION / TI ❑ REVISION! DEFERRED ORIGINAL PERMIT # PROJECT ADDRES'S JO"I s De AN2A $L -VD A APNM35C) 1'T p J�'. f 4y7 �- OWNER NAME ROS A N Lo PHONE b�to - y 1't - t?,pti`^a roscin 10 8833 ® 31mq'� • caws STREET ADDRESS f I J bbRk VAT C'C J T CITY, STATE, ZIP �,,,1IOITA•S , Ch qiD� FAX CONTACT NAME ��AcV AA1?6m l rP,c-rvR� p PHONE t -IO t FSZ 26 d E MAQ. JaCE JoIC�LIrGh+ FPLfI /rE• C0►17 STREET ADDRESSrd 'S1. SV1tE 7� �j 2v 3 CITY, STATE. ZIP p O�K�Ru� , (!A q4d 7 FAX ❑ OWNER ❑ OWNER -DUI DER l *.1 C1VaZ RAGENT ❑ comRAcToR ❑ LomntAcToRAGENT ❑ ARcrmcr ❑ a*rrNEEt ❑ DRVEIDPER ❑ TENANT CONTRACTOR NAItiffijvA N PA r LICENSE NUMBER�7 2! E --MA LICENSE TYPE � BUS. LIC M 4 COMPANY NAME CaRaMf WPrW G01.1 SrtWJG-ftON IIJG E l VAS IQ JI P a o W e-4 A 4a o. c a M FAX 1—_, STREET ADDRESS t4 -C, -L-13 SI`t I-V I Q ] CrrY, &TATE. ZIP t5A N LF�t� i� ct� ` L 5' `�$ PHONE S 10 S$ g -1528 5 ARCHITECTIENGINHEE R NAME { �, Gr I r 1 t�f So r� G L� LICENSE NUMBER G `� '2, 0 •1 15 BUS. LIC N COMPANYNAME �}F.CE �tt�FfrT��M EMAIL {Rr�e ACEARclt1lCcM+�. FAX STREET ADDRESS Ca SD J14 S7' SvHE �°O CJTY,STATE,ZIP 0A' CA,- A Go -7 }- PHONE 417 4Td DESCRIPTION OF WORK_, t A� U �]E [ cT 15 X" l kr � S -1 a lL I of 1 p 1 P-E:STPrU(LNNi . SG°PE °f� WdRl K- !N C-t_UO ES FULL !ZEJLUeT-- l4(RffC1J I ew-k}l27- � &G (LV l c.� -MEGA , 131 "INC-, 1 uN ► six R]EsrMu��rJ-r. Pd ST0-vGTbXL-A L- w0RJl . BMTRI* USE I PROPOSED USE CONSTR. TYPE F STORIES [) - 1)Rt4 CLQ .d, (i S-�U ai�-t+ 3 - B i USE ME OCC. Fr.. VALUATION (S) AARA REG 1 t{' t1O AAR� r AREA DEMO AREA �— TOTAL 3 / TJ} NET AREA I Li 9 I JSQ BATHROOM KUTCHEN OTHER REMODEL AREA - REMODELAREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK WRCH AREA GARAGE AREA: DETACH I ATTACH 4DWEI].I C,LRIM: tSASECONDUNIT 0YES BEINGADnED? SECO.IIUSTORY ❑YES ADDITION? 1090 10176 PRE -APPLICATION ❑Y -S IF YES. PROVIM �• PLAWNDJO APDL 9 O PANNING AP tR IS THE BLDG AN r] YES • EiCHLER HO►tE7 � IQ6 RECEIVEDB _QiCI�IJ.� N: / i "p� f L O rry owner or authorized agent to act on the property owner's behalf. 1 have read this By my signature below, I certify LO each of the £0110w1ng: I7.,K. application and the intbnnation 1 have pinvided is ct. I haDescription of Work and verify it is accurate. I agree to wmply with a!I applicable local ordinances and state laws relating to buil ' g�onslntction. iarepresentatives of Cupertino to enter the above-idenfified property for inspection purposes. Signature of A omfau#IAgee1C' Date: fqomFr_ SUPPL INFO TION REQUIRED PLANCnECKTYPE ROIMNG SUP ❑ OVER-THE-COUNTERBUILDING PIAN REVJK%V New SFD or Multifamily dmelIings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ E.YPRES_5 PLxTIPHhG PLAN "VIF%V _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 11 STANDARD 13PUBLICIYORKS fotTn if any Hazardous Materials are being used as part of this project. ❑ LARGE nRE OFFT _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. 21WOR SAMTARY SEVITiR DISTRICT ❑ FNVIRONt1iENTALItF.ALTII BldgApp_2011.doc revised 0621/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10477 s de anza blvd DATE: 03102/2015 REVIEWED BY: Mendez DPN: BP#: -VALUATION: 1$167,500 %PERMIT TYPE: Building Permit PLAN CHECK TYP : Tenant Improvement PRIMARY Commercial Building PENTAMATION 1 B TI USE: I PERMIT TYPE: WORK I verde tea house' comm. t.i to include interior improvements 1448 s -ft SCOPE OCCUPANCY TYPE: TYPE OF CONSTP FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-S,IIi-S,IV,V-B 1,448 $2,160.12 IBTIPLNCK $1,408.32 IBTIINSP h"Iec. Insp. Pee: $1,408.32 Suppl. Insp. Fee:Q Reg. 0 OT 0 0 hrs $0.00 PME Unit Fee. $0.00 PME Permit Fee: $0.00 Cvnsirurtion Tax; ?dmlwslralive Fee: Select a Non -Residential Q Building or Structure Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee. $0.00 TOTALS: 1,448 $2,160.12 Strong Motion Fee_ 1BSEISMICO $1,408.32 Select an Administrative Item MECH, HOURLY 0 Yes 0 No PLUMB, HOURLY 0 Yes Q No ELEC, HOURLY 0 Yes Q No Meeh, 111cm Check Phonh. Plan ('hcc6 E7ec. Plan Check Meeh. perwit Fee: Plrrnrb. Permir Fee: rlee Perrnir Fee rollf',"'111,hrech. Insp Other Phrmb Insp 0drer Elec. hlsp. ED hlsp. Few Phoub, Insp. Fee: h"Iec. Insp. Pee: NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School bictrirt. a/r_ )_ T/reee fePe are haled nn the nrefiminary information availahle and are aniv an estimate. Contact the Dent for addn'f info. FEE ITEMS Lee Resolution 11-053 Eli` 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,160.12 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,408.32 Suppl. Insp. Fee:Q Reg. 0 OT 0 0 hrs $0.00 PME Unit Fee. $0.00 PME Permit Fee: $0.00 Cvnsirurtion Tax; ?dmlwslralive Fee: Select a Non -Residential Q Building or Structure Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee. $0.00 Select a Non -Residential 0 Building or Structure 0 i Trmwl Documentation Fees: Strong Motion Fee_ 1BSEISMICO $52.50 Select an Administrative Item Blde Stds Commission Fee: 1BCBSC $8.00 SUBTOTALS: $3,628.94 $0.00 TOTAL FEE: 1 $3,628.94 Revised: 02/14/2015 .y CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10477 S DE ANZA BLVD CONTRACTOR: GREATWALL BLDG PERMIT NO: 15030019 CONTRACTOR INC OWNER'S NAME: BDC HAYWARD L.P 1689 VISTAGRAND DR DATE ISSUED: 06/11/2015 OWNER'S PHONE: 6507148833 SAN LEANDRO, CA 94577 PHONE NO: (510) 589-7528 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTIO ❑ N: RESIDENTIAL COMMERCIAL VERDE TEA HOUSE; SUITE A; COMM. T.I TO INCLUDE License Class j_ Lie. # S S INTERIOR IMPROVEMENTS 1448 SQ FT Contractor _4 CZA 41 4? Z 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: $187500 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: 35917019.10477 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 O T ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save 18Q D LED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of granting of this permit. Additionally, the applicant understands and will comp ate: with all non -points urce regulations per the Cupertino Municipal Codec 'on 918. 1L.jy/ l/' ,� Signature Date v�J ROOFS: All roofs shall be inspected prior any r or to y 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: I, as owner of the property, or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER will do the work, and the structure is not intended or offered for sale (See.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 I hereby affirm under penalty of perjury one of the following three California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Health & Safety Code, Section 25532(a) should I store or handle hazardous 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 Distri performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.1 nd I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Owner or authorized agent: Date 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 Lender's Address 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, ARCHITECT'S DECLARATION 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 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Ton -c Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB A DDRESS:1 0477 S De Anza Blvd PERMIT { 150300/9 OWNER'S NAME:BDC Hayward L.P. PHONE 4(510) 589-7528 CONTRACTOR:Greatwall Building Contractor, Inc. BUSINESS LICENSE #30381 _ _GENERAL ADDRESS:1689 Vistagrand Drive CITY/ZIPCODE:San Leandro 94577 *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 S B T TORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 1 am not using any subcontractors: - — Signature Date Please check applicable subcontractors and complete the following information: t/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass! Glazing Heating Insulation Landscaping Lathing.�-_. .�.._..... _— _�......__ W_-..�.�.�._. Masonry Painting / Walipaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Conti -actor Signature Date CALGREEN NON-RESIDENTIAL CHECKLIST — IVIANDATORY ITEMS COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION , CUPERTINO ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFIC 10300 TORRE AVENUE - CUPERTINO, pla & CA 950UU T (408) 777-3228 • FAX (408) 777-3333 • buildin Jrcu e PURPOSE: The non-residential provisions of the 2013 CalGreen Code outline planning, design and development methods that include environmentally responsible site selection, building design, building siting and development to protect, restore and enhance the environmental quality of the site and respect the integrity of adjacent properties; establishes the means of conserving water used indoors, outdoors and in wastewater conveyance; outlines means of achieving material conservation and resource efficiency; and outlines means of reducing the quantity of air contaminants. Project Name: VERDE TEA CAFE Project Address: 19620 Stevens Creek Blvd. Ste.# 180 Project Description: Tenant I Instructions: 1 1. The Owner or the Owner's agent shall employ a licensed professional experienced with the 2013 California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. 2. The licensed professional, in collaboration with the owner and the design professional shall initial IiA�Lg7dkstigflnd checklist, sign and date Section 1 - Design Verificationat the end of this checklist cklist printed on the approved plans.for the project. ection by the Building Department, the licensed professional shall complete Column -3' o Section 2 - Implementation Verification at the end of this checklist and submit the to the Building Inspector. Column 2 Column 3 MANDATORY FEATURE OR MEASURE Project Verification Reauirements u General :Requirements The project meets all the requirements of Divisions 5.101 through 5.508. I ® 1 ❑ Planning and Design -Site Development 5.106.1 Storm water pollution prevention. For projects of one acre or less, develop a Storm Water Pollution Prevention Plan (SVVPPP) that has been designed; specific to its site, conforming to the State Storm water NPDES Construction Permit or local ordinance, whichever is stricter, as is required for ❑ ❑ projects over one acre. The plan should cover prevention of soil loss by storm water nun -off andforwind erosion, of sedimentation andfor of dustfparficulate matter air pollution. Page 1 of 9 CalGreen Non -Res Checklist doc revised 01123114 5.106.4 Bicycle parking. Comply with Sections 5.106.4.1 and 5.106.4.2; or local is ® ❑ meet ordinance, whichever stricter. 5.106.4.1.1 ShortTerm bicycle parking. If the qualified project is anticipated to generate visitor traffic, provide permanently anchored bicycle racks within 200 feet of the visitors' entrance, readily visible to passers-by, ® ❑ for 5 percent of visitor motorized vehicle parking spaces being added, with a minimum of one two -bike capacity rack. 6.106.4.1.2 Long Term bicycle parking. For qualified buildings with over © ❑ 10 tenant -occupants, provide secure bicycle parking for 5 percent of tenant vehicle parking spaces being added, with a minimum of one space. 5.106.5.2 Designated parking. Provide designated parking for any combination of lowemitting, fuel-oifident and carpool/van pool vehicles as ® ❑ shown in Table 5.106.52. 5.106.8 Light pollution reduction. Outdoor lighting systems shall be ® ❑ designed and installed to comply with the following: 1. The minimum requirements in the California Energy Code for lighting zones 1 —4 asAefined in Chapter 10 of the California Administrative Code; and 2. Backlight, Uplight and Glare (BUG) ratings as defined in IES TM -15-11; and ❑ ❑ 3. Allowable BUG rating not exceeding those shown in Table 5.106.8, or ❑ ❑ Comply with a local ordinance lawfully enacted pursuant to Section 101.7, whichever is more stringent 5.106.10 Grading and paving. The site shall be planned and developed to keep surface water away from buildings. Construction plans shall indicate how ❑ ❑ site grading or a drainage system will manage all surface water flows. Division Performance Requirements 5.201.1 Scope. The California Energy Commission will continue to adopt ® ❑ mandatory building standards. Division• • Indoor Water Use 5.303.1 Meters. Separate meters shall be installed for the uses described in Sections 503.1.1 and 503.1.2. 5.303.1.1 Now building or additions in excess of 50,000 square feet ❑ ❑ Separate submeters shall be installed as follows: 1. For each individual leased, rented or other tenant space within the ❑ ❑ building projected to consume more than 100 gal/day. 2. Where separate submeters are unfeasible, for water supplied to the following systems: a. Makeup water for cooling towers where flow through is greater ❑ ❑ than 500 gpm. b. Makeup water for evaporative coolers greater than 6 gpm. c. Steam and hot-water boilers with energy input > 500,000 Bluth. Page 2 of 9 CalGreen, Non -lies Checklist doc revised 01123114 5.303.1.2 Excess consumption. A separate submeter shall be provided for any tenant within a new building or within an addition that is projected ❑ ❑ to consume > 1,000 gaUday. 5.303.2 Water reduction. Plumbing fixtures shall meet the maximum flow rate ® ❑ values shown in Table 5,303.2.3. Exception: Building that demonstrate 20 -percent overall water use reduction. 5.303.2.1 Areas of addition or alteration. For those occupancies within the authority of the California Building Standards Commission, as specified in Section 103, the provisions of Section 5.303.2 and Section 5.303.3 shall ® ❑ apply to new fixtures in additions or areas of alterations to the buildings. 5.303.4 Wastewater reduction. Each building shall reduce by 20 percent wastewater by one of the following methods: 1. The installation of water -conserving fixtures or ® ❑ 2. Utilizing non -potable water systems. ❑ ❑ 5.303.6 Standards for plumbing fixtures and fittings. Plumbing fixtures and fittings shall be installed in accordance with the California Plumbing Code ® ❑ (CPC), and shall meet the applicable standards referenced in CPC Table 1401.1 and CaiGreen Chapter 6. Outdoor Water Use 5.304.1 Water budget. A water budget shall be developed for landscape ❑ ❑ irrigation use. 5.304.2 Outdoor potable water use. For new water service or for addition or alteration requiring upgraded water service for landscaped areas of at least ❑ ❑ 1,000 sq.ft. but not more than 5,000 sq.ft., separate submeters or metering devices shall be installed for outdoor potable water use. 5.304.3 Mgatlon design. In new nonresidential construction or building addition or alteration with at least 1,000 but not more than 2,500 sq.ft. of cumulative landscaped area, install irrigation controllers and sensors which ❑ ❑ include the following criteria, and meet manufacturer's recommendations. 5.304.3.1 Irrigation controllers. Automatic irrigation system controllers installed at the time of final inspection shall comply with the following: 1. Controllers shall be weather- or soil moisture -based controllers that automatically adjust irrigation in response to changes in plants' needs as ❑ ❑ weather conditions change. 2. Weather -based controllers without integral rain sensors or communication systems that account for local rainfall shall have a separate wired or wireless rain sensor which connects or communicates ❑ ❑ with the controller(s). Soil moisture -based controllers are not required to have rain sensor input. Weather Resistance and Moisture Management 5.407.1 Weather protection. Provide a weather -resistant exterior wall and foundation envelope as required by Califomia Building Code Section 1403.2 ❑ ❑ and Califomia Energy Code Section 150, manufacturer's installation instructions or local ordinance, whichever is more stringent.' Page 3 of 9 CalGreen ]Von -Hes Checklist doc revised 01123/14 5.407.2 Moisture control. Employ moisture control measures by the following methods; 5.407.2.1 Sprinklers. Prevent irrigation spray on structures. ❑ ❑ 5.407.2.2 Entries and openings. Design exterior entries and/or openings ❑ ❑ to prevent water intrusion into buildings. 5.407.2.2.1 Exterior door protection. Primary exterior entries shall be covered to prevent water intrusion by using nonabsorbent floor and ❑ ❑ wall finishes within at least 2 ft around and perpendicular to such openings plus at least one of the following: 1. An installed awning at least 4 ft in depth. 2. The door is protected by a roof overhang at least 4 ft in depth, 3. The door is recessed at least 4 ft. 4. Other methods which provide equivalent protection. 5.407.2.2.2 Flashing. Install flashings integrated with a drainage ❑ ❑ plane. Construction Waste Reduction, Disposal and Recycling 5.408.1 Construction waste management. Recycle and/or salvage for reuse a minimum of 50 percent of the nonhazardous construction and demolition waste in accordance with Section 5.408.1.1, 5.408.1.2, or 5.408.1.3; or meet a ❑ ❑ local construction and demolition waste management ordinance, whichever is more stringent. 5.408.1.1 Construction waste management plan. Submit plan per this ❑ ❑ section to enforcement authority. 5.408.1.2 Waste management company. Utilize a waste management company that can provide verifiable documentation that the percentage of ® ❑ construction and demolition waste material diverted from the landfill complies with CalGreen Section 5.408. 5.408.1.3 Waste stream reduction alternative. The combined weight of new construction disposal that does not exceed two pounds per square ❑ ❑ foot of building area may be deemed to meet the 50 percent minimum requirement as approved by the enforcing agency. 5.408.1.4 Documentation. Provide documentation of the waste ❑ ❑ management plan that meets the requirements listed in Section 5.408.1.1 through 5.408.1.3. 5.408.3 Excavated soil and land clearing debris. 100 percent of trees, stumps, rocks and associated vegetation and soils resulting primarily from land ❑ ❑ Gearing shall be reused or recycled. Building Maintenance and Operation 5.410.1 Recycling by occupants. Provide readily accessible areas that serve the entire building and are identified for the depositing, storage and collection ® ❑ of nonhazardous materials for recycling. 5.410.2 Commissioning. For new buildings 10,000 square feet and over, building commissioning for all building systems covered by T24, Part 6, process systems and renewable energy systems shall be included in the ❑ ❑ design and construction processes of the building project. Commissioning requirements shall include items listed in Section 5.410.2. Page 4 of 9 CalGreen Non -Res Checkhst dcc revised 01123114 5.410.2.1 Owner's Project Requirements (OPR). Documented before the design phase of the project begins the OPR shall include items listed in ❑ ❑ Section 5.410.4. 5.410.2.2 Basis of Design (BOD). A written explanation of how the design of the building systems meets the OPR shall be completed at the design phase of the building project and updated periodically to cover the systems ❑ ❑ listed in Section 5.410.2.2. 5.410.2.3 Commissioning plan. A commissioning plan describing how the project will be commissioned shall be started during the design phase of ❑ ❑ the building project and shall include items listed in Section 5.410.2.3. 5.410.2.4 Functional performance testing. Functional performance testing shall demonstrate the correct installation and operation of each component, system and system -to -system interface in accordance with the ❑ ❑ approved plans and specifications. 5.410.2.5 Documentation and training. A Systems manual and systems operations training are required. ❑ ❑ 5.410.2.5.1 Systems manual. The systems manual shall be delivered to the building owner or representative and facilities operator and shall ❑ ❑ include the items listed in Section 5.410.2.5.1. 5.410.2.5.2 Systems operations training. The training of the appropriate maintenance staff for each equipment type and/or system ❑ ❑ shall include items listed in Section 5.410.2.5.2. 5.410.2.6 Commissioning report. A complete report of commissioning process activities undertaken through the design, construction and ❑ ❑ reporting recommendations for post-mristruction phases of the building project shall be completed and provided to the owner or representative. 5.410.4 Testing and adjusting. Testing and adjusting of systems shall be required for buildings less than 10,000 square feet or new systems to serve an addition or alteration subject to Section 303.1. 5.410.4.2 Systems. Develop a written plan of procedures for testingand adjusting systems. Systems to be included for testing and adjusting shall include, as applicable to the project, the systems listed in Section ❑ ❑ 5.410.3.2. 5.410.4.3 Procedures. Perform testing and adjusting procedures in accordance with industry best practices and applicable national standards on each system. 5.410.4.3.1 HVAC balancing. Before a new space -conditioning system serving a building or space is operated for normal use, the system should be balanced in accordance with the procedures defined by ® ❑ national standards listed in Section 5.410.3.3.1. 5.410.4.4 Reporting. After completion of testing, adjusting and balancing, provide a Final report of testing signed by the individual responsible for ® ❑ performing these services. 5.410.4.5 Operation and maintenance manual. Provide the building owner with detailed operating and maintenance instructions and copies of ® ❑ guarantiestwarranties for each system prior to final inspection. 5.410.4.5.1 Inspections and reports. Include a copy of all inspection © El and reports required by the enforcing agency. Page 5 of 9 CdGreen Non -Res Checklist. doc revised 01123114 Fireplaces 5.503.1 Install only a direct -vent sealed -combustion gas or sealed wood- buming fireplace or a sealed woodstove and refer to residential requirements ❑ ❑ in the California Energy Code, Title 24, Part 6, Subchapter 7, Section 150. 5.503.1.1 Woodstoves. Woodstoves shall comply with US EPA Phase 11 1:1 1:1emission limits. Pollutant Control 5.504.3 Covering of duct openings and protection of mechanical equipment during construction. At the time of rough installation or during storage on the construction site and until final startup of the heating and cooling equipment, all duct and other related air distribution component ® ❑ openings shall be covered with tape, plastic, sheet metal or other methods acceptable to the enforcing agency to reduce the amount of dust or debris which may collect in the system. 5.504.4 Finish material pollutant control. Finish materials shall comply with Sections 5.504.4.1 through 5.504.4.4. 5.504.4.1 Adhesives, sealants, caulks. Adhesives and sealants used on the project shall meet the requirements of the following standards. 1. Adhesives, adhesive bonding primers, adhesive primers, sealants, sealant primers and caulks shall comply with local or regional air pollution control or air quality management district rules where applicable or ® ❑ SCAQMD Rule 1168 VOC limits, as shown in Tables 5.504.4.1 and 5.504.4.2. 2. Aerosol adhesives and smaller unit sizes of adhesives and sealant or caulking compounds (in units of product, less packaging, which do not weigh more than one pound and do not consist of more than 16 fluid ounces) shall comply with statewide VOC standards and other ® ❑ requirements, including prohibitions on use of certain toxic compounds, of California Code of Regulations, Title 17, commencing with Section 94507. 5.504.4.3 Paints and coatings. Architectural paints and coatings shall comply with Table 5.504.4.3 unless more stringent local limits apply. ® ❑ 5.504.4.3.1 Aerosol paints and coatings. Aerosol paints and coatings shall meet the Product -Weighted MIR Limits for ROC in Section 94522(x)(3) and other requirements, including prohibitions on use of ® ❑ certain toxic compounds and ozone depleting substances (CCR, Title 17, Section 94520 et seq). 5.504.4.3.2 Verification. Verification of compliance with this section shall be provided at the request of the enforcing agency. ® ❑ 5.504.4.4 Carpet systems. All carpet installed in the building interior shall meet the testing and product requirements of at least one of the standards ❑ ❑ listed in Section 5.504.4.4. 5.504.4.4.1 Carpet cushion. All carpet cushion installed in the building interior shall meet the requirements of the Carpet and Rug Institute ❑ El Label program. 5.504.4.4.2 Carpet adhesive. All carpet adhesive shall meet the requirements of Table 5.504.4.1. ❑ ❑ Page 6 of 9 CalGreen Non Rev Checklivl.doc revived 01123114 5.504.4.5 Composite wood products. Hardwood plywood, particleboard and medium density fiberboard composite wood products used on the interior or exterior of the building shall meet the requirements for ® ❑ formaldehyde as specified in Table 5.504.4.5. 5.504.4.5.3 Documentation. Verification of compliance with this section ❑ shall be provided as requested by the enforcing agency. Documentation shall include at least one of the following standards listed in Section 5.504.5.3. 5.504.4.6 Resilient flooring systems. For 80 percent of floor area receiving resilient flooring, installed resilient flooring shall meet at least one ® ❑ of the following standards listed in Section 5.504.4.6. 6.604.5.3 Filters. In mechanically ventilated buildings, provide regularly occupied areas of the building with air Filtration media for outside and ® ❑ return air prior to occupancy that provides at least a MERV of 8. 5.604.7 Environmental tobacco smoke (ETS) control. Prohibit smoking within 25 feet of building entries, outdoor air intakes and operable windows where outdoor areas are provided for smoking and in buildings; or as enforced ® ❑ by ordinances, regulations or policies of any city, county, city and county, California Community College, campus of the California State University or campus of the University of California, whichever are more stringent. Indoor Moisture and Radon Control 5.505.1 Indoor moisture control. Buildings shall meet or exceed the provisions of Califomia Building Code, CCR, Title 24, Part 2, Sections 1203 ❑ ❑ and Chapter 14.1. Air Quality and Exhaust 5.606.1 Outside air delivery. For mechanically or naturally ventilated spaces in buildings, meet the minimum requirements of Section 121 of the California ® ❑ Energy Code, CCR, Title 24, Part 6 and Chapter 4 of CCR, Title 8 or the applicable local code, whichever is more stringent' 5.606.2 Carbon dioxide (CO2) monitoring. For buildings equipped with demand control ventilation, CO2 sensors and ventilation controls shall be ® ❑ specified and installed in accordance with the requirements of the latest edition of the Calitbrnia Energy Code, CCR, Title 24, Part 6, Section 121(c).' Environmental Comfort 5.507.4 Acoustical control. Employ building assemblies and components ❑ ❑ with STC values determined in accordance with ASTM E 90 and ASTM E 413. 5.507.4.1 Exterior noise transmission. Wall and floor -ceiling assemblies making up the building envelope shall have an STC of at least 50 and exterior windows shall have a minimum STC of 30 for any of the building ❑ ❑ locations listed in items 1 through 3 in Section 5.507.5.1. 5.507.4.2 Interior sound. Wall and floor -ceiling assemblies separating tenant spaces and tenant spaces and public places shall have an STC of ❑ ❑ at least 40. Page 7 o£9 ColGreen Non Res Clmcklisl.doc revised 011231!4 Outdoor Air Quality 5.508.1 Ozone depletion and greenhouse gas reductions. Installations of HVAC, refrigeration and fire suppression equipment shall comply with Sections 5.508.1.1 and 5.508.1.2. 5.508.1.1 Chlorofluorocarbons (CFCs). Install HVAC and refrigeration equipment that does not contain CFCs. 5.508.1.2 Halons. Install fire suppression equipment that does not contain ® ❑ Halons. Page 8 of 9 CalGreen Non -Res Cherklistdoc revised 01/23119 Project Name: CALGREEN SIGNATURE DECLARATIONS VERDE TEA CAFE Project address: 19620 Stevens Creek Blvd. Ste.# 180. Project Description: Tenant. Improvement SECTION 1— DESIGN VERIFICATION Complete all lines of Section i — "Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the,project plane and will be implemented into the project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as adopted by the City of Cupertino. 02!2112015 Owner's Signature Date Rosan LO Owner's Name (Please Print) 02124/2015 Design Professional's Signature Date JHP Engineering and Design- Jia Hui Pan Lic# M35374 Design Professional's Name (Please Print) �W 02121/2015 Signature of License Professional respo Bible 6 ree compliance Date Jam Hezar, ICC1CalGreen Inspector 80993$0 (530) 902-0387 Name of License Professional responsible forCa1G en compliance (Please Print) Phone a24T@aft.net `\ Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all Original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2013 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Jam Hezar ICC1CalGreen Inspector 8099390 (530) 902-0387 Name of License Professional responsible for CalGreen compliance (Please Print) Phone nage 9 or9 ColGreen Va--Rec ChecldliAdoc mvised 0112Y14 CALGREEN SIGNATURE DECLARATIONS Project Name: VERDE TEA HOUSE Project Address: 10477 South De Anza Blvd. Cupertino, CA 95105 Project Description: Tenant Improvement SECTION 1 — DESIGN VERIFICATION Complete all tines of Section 1—'Design Verification' and submit the entire checKst (Columns 2 and 3) with the plans and building permit application to the, Building Department. The owner and design professional responsible for compliance vett CalGreen Standards have reviewed the pians and certify that the items checked above are hereby incorporated info the project plans and wib he implemented irrto the project In accordance with the requirements set forth In the 2013 Callfamla Green Building Standards Code as adopted by the City of Los Altos. s- syr /_5 -- Date Rosan LO Owner's Name ase Print) S. /ch• Ir Design essional's ignature Date Jace Levinson, Principal, LEED-AP C-23075 Design Professlonal's Name (Please Print) Signature of Licensed Professional—re for CalGreen compliance Jam He=r, ICCfCatGrwn Inspector SE0009390 Name of Licensed Professional responsible for Cal0men compliance (Please Print) o24te2tinot Email Address for Licensed Professional responsible for CalGFeen compliance 02/2102015 - Date (S30) 802-4367 Phone No. SECTION 2 — IMPLEMENTATION VERIFICATION Complete, sign and submit the completed checklist including column 3, tDgedw with all original signatures on Section 2 to the Building Department PRIOR TO BUILDING DEPARTMENT FINAL INSPECTION. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2013 California Green Building Standards Code as adopted by the City of Los Altus. Signature of Licensed Professional responsible for CalGreen Compliance Date Jam Homr, ICC,CalGroen Inspetor 0&4090390 (530) 902-787 Name of Licensed Professional responsible fol CalGi een compliance (Please Prue) Phone No. a24t@attrwt Email address for Licensed Professional responslble for CalGreen compliance ** This form mu be completed and returned to the City of Los Altos prior to your final inspection"