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15020045CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: 15020045 19399 STEVENS CREEK BLVD CUPERTINO CA 95014 PARKWAY CONSTRUCTION 1000 CIVIC CIRCLE LEWISVILLE, TX 75067 OWNER'S NAME: SAND HILL PROPERTY COMPANY DATE ISSUED: 07/10/2015 OWNER'S PHONE: 6503441500 PHONE NO: 4693223752 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: r License Class # qa � is �TI Contractor P KWAY to 2/23/2016 BLDG —ELECT —PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing RESIDENTIAL — MECH _ — COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: LYFE KITCHEN,COMM.T.I ON(E)SHELL BUILDING 4,092 SQ I hereby affirm under penalty of perjury one of the following two declarations: FT 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 REV # 1 - ROOF TOP EQUIPMENT DETAILS, ADD OUTLET & _. performance of the work for which this permit is issued. KITCHEN EQUIPMENT CHANGES - ISSUED 2/23/2016 z. I have and will maintain Worker's Compensation Insurance, as provided for J by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $835000.00 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 APN Number: Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED granting of this permit. Additionally, the applicant understands and will WITHIN 180 DAYS OF PERMIT ISSUANCE OR comply with all non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION. Code, Section 9.18.x, ` ^ Signature Date 2/23/2016 Issued by: PAUL O'SULLIVAN t Date: 2/23/2016 �1 OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: All roofs shall be inspected prior to any roofing material being installed, If a roof is installed first inspection, I to for 1. I, as owner of the property, or my employees with wages as their sole without, obtaining an agree remove all new materials inspection. compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: z. I, as owner of the property, am exclusively contracting with licensed Date: 2/23/2016 contractors to consttuct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the z. I have and will maintain Worker's Compensation Insurance, as provided for California Health & Safety Code, Sections 25505, 25533, and 25534. I will by Section 3700 of the Labor Code, for the performance of the work for which maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the this permit is issued. Health & Safety Code, Section 25532(a) should I store or handle hazardous 3. I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code,-,Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shalt be deemed revoked. Owner or authorized agent: Iff Date: 2/23/2016 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant ARCHITECT'S DECLARATION understands and will comply with all non-point source regulations per the I understand my plans shall be used as public records. Cupertino Municipal Code, Section 9.18. Licensed Signature Date 2/23/2016 Professional NF.W LYINCTRT V'TTr)xT CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a)-cupertino.org F-1 A TlTl I- 171 I V -I ----- �. _�_������+ 1■ u r11nVI13IUIN/I)hVhxxrll 0RIGINAL PERMIT # 1OVLUU40 PROJECT ADDRESS APN # 19399 Stevens Creek Blvd. Cupertino, CA 95014 OWNER NAME PHONE E-MAIL Sand Hill Property Co 650.344.1500 disaacs@shpco.com STREET ADDRESS CITY, STATE, ZIP FAX 2882 Sand Hill Road, Suite 241 Menlo Park, CA 94025 CONTACT NAME Austin Tull PHONE E-MAIL, 469.322.3748 atull@pkwycon.com p wycon.com STREET ADDRESS 1000 Civic Circle CITY, STATE, ZIP FAX Lewisville TX 75067 ❑ OWNER ❑ OWNER -BUILDER 1l OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT IN ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME Christie Schachter _ LICENSE NUMBER. Applied for LICENSE TYPE BUS. LIC # COMPANY NAME _--- -- Parkway Construction &Architecture, LP E-MAILFAX cschachter@PkMcon.com STREET ADDRESS 1000 Civic Circle CITY, STATE, ZIP - - Lewisville, TX PHONE 75067 469.322.3733 ARCHITECT/ENGINEER NAME Grea Kimko LICENSE NUMBER BUS. LIC # 33391 COMPANY NAME E-MAIL prelshus@pkwycon.com - Parkway Construction & Associates, LP FAX atull@pkwvcon.com STREET ADDRESS - 1000 Civic Circle CITY, STATE; ZIP -. Lewisville, TX 75067 PHONE 469.322.3752 _. DESCRIPTION OF WORK - .... Revisions to the previous permitted drawings for the LYFE Kitchen tenant finish -out. Revision information includes: anchorage for roof top equipment, mount for water heater and water softener, electrical outlet EXISTINGUSE PROPOSED USE - CONSTR TYPE # STORIES - - - �C_B 1 1 USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG AREA NEW FLOOR AREA DEMO AREA TOTAL - NET AREA Restaurant 144 4,092 SF BATHROOM - - KITCHEN OTHER -- REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH - - N/A []ATTACH #DWELLINGUNTTS: IS ASECOND UNIT ❑YES SECONDSTORY ❑YES - BEING ADDED? []NO ADDITION? MNO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES ! TOTAL VALUATION: PLANNING ADPL # [I NO PLANNING APPROVAL LETTER EICHLER HOME? M N " By my signature below, I certify to each o/thPollowin he property owner or authorize agent to a thepr�pe owner's behalf. I happlication and the information I have pr is c ect. I have zead the-Descri tion of Work and veri Iagree to comply with all applicable local ordinances and state laws relating to b onstivetiou: I a t orize represent t ves of Cupertino to enter the ab u identified property for inspection purposes. Signature of ApplicantlAgent: Date: 41, 3— SUPPLEMENTAL INFO ION REQUIRED FNCHEez�UT sLz�; _ New SFD or Multifamily dwellings: Apply for demolition permit for o VET, TSE caIII TER © LI}31 +G R existing building(s). Demolition permit is required prior to issuance of building PLAN iFIEtiY permit for new building. Q EXPPKESS ❑ VIANNINO•_PLAWREVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 0 STA �TDARD C� �rrslzc Wllluzs form if any Hazardous Materials are being used as part of this project. C) ARG& ❑ tPT _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. nra TOR ❑-UNUARY SEWM7iTS RTr T © FNvTRONwNTAL HEALTH BldgApp 2011.doc revised 06121111 E CITY OP'=CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19399 STEVENS CREEK BLVD CONTRACTOR: PARKWAY PERMIT NO: 15020045 CONSTRUCTION & OWNER'S NAME: MAIN STREET CUPERTINO AGGREGATOR LL 1000 CIVIC CIR DATE ISSUED: 07/10/2015 OWNER'S PHONE: 6503441500LEWISVII LE, TX 75067 PHONE NO: (469) 322-3768 _i LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL -- - - f � LYFE KITCHEN, COMM. T.I ON (E) SHELL BUILDING License Class Lic. # 4,092 S FT Contractor 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: $835000 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 31620109.19399 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 FRO INSPEC ION. indemnify and keep harmless the City o ertino a ainst liabilities, judgments, costs, and a icb may accru agains said City "n consequence of the / /� ddif Issued by: a S granting�is permit. n the appl"cant and stands and will comply with alli on -point source a latio p r the upertino unicipal Code, Section 9.18. t i] RE-ROOFS:ong Signature Date 7 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: 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 (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.Ouality Management District I performance of the work for which this permit is issued. will maintain compliance i i, •pal, o , Chapter 9.I2 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Cod , SectionAn 25534. r!! Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized age t: Date: i� 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 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 $Idb.fp1 ?I1fl.docrevused(J61?I,tl CITY OF CUPERTINO FEE FSTIA4 A TnR — 11IT11,11INCZ "1rV114Q11n1V DRESS: 19399 Stevens,Creek Blvd. DATE: 02105/2015 REVIEWED BY: jia�ff� I BP#: 001 - "VALUATION: I E835,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY USE: Commercial Building II-I3,III-l3,IV,V-B PENTAMATION PERMIT TYPE: 1A T1 A WORK IATIPLNCK SCOPE ]A TIINSP OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA (s.f.) PC FEES PC FEE ID BP FEES BP FEE ID A (Tenant Improvements) II-I3,III-l3,IV,V-B 4,092 $2,672.44 IATIPLNCK $2,196.12 ]A TIINSP $0.00- PME Plan Check: $0.00 Permit Fee: $2,196.12_ Suppl. Insp. Fee:G Reg. 0 OT 10701 hrs $0.00 PME Unit Fee: $0.00 PME Per mit Fee: $0.00 TOTALS: 4,092 $2,672.44 -2 $2,196.12 MECH, HOURLY 0 Yes 0 No, PLUMB, HOURLY� 0 Yes E) No '"ELEC,HOURLY 0 Yes '(F)No J Lj I NOTE.* This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School FEE ITEMS (Fee Resolution 11-053 Eff. 7X13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,672.44 Select a Misc Bldg/Structure qr Element of a Building Suppl. PC Fee: E) Reg. 0 OTFO - 071 hrs $0.00- PME Plan Check: $0.00 Permit Fee: $2,196.12_ Suppl. Insp. Fee:G Reg. 0 OT 10701 hrs $0.00 PME Unit Fee: $0.00 PME Per mit Fee: $0.00 -2 T7 E) Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 Strong Motion Fee: IBSEISAffCO $233.80 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $34.00 SUBTOTALS: $5,136.361 $0.001 $5,136.361 Revised: 01/06/2015 CITY OF CUPERTINO FFF. FgT1MATnR _ RTTI1.nYNV n1VTCTnw iaADDRESS: 19339 STEVENS CREEK BLVD DATE: 09/25/2015 REVIEWED BY: MELISSA APN: 316 20 114 BP#: 15020045 r *VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY Commercial Building USE: Civil /"Religious activities in BQ zone? 0 Yes (F) No PENTAMATION PERMIT TYPE: WORK REV # 1 -ROOFTOP EQUIPMENT DETAILS ADD OUTLET & KITCHEN EQUIPMENT CHANGES SCOPE , $0.00 :-Vech. flan Check r,Iech, Perarrit Fee: , Plumb -Plan Check Flee. Plan Check Plumb, Permit Fee: tJlec. Perneit Fee: Other. _ilech. Insp. I I Other Plan b lrrsp� Other Elec. Imp, u Idech, hop. Fee: 1 Pha nb. fits/a. Fee: l;lec. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning. Public Works. Fire. Sanitary Sewer District. School District. etc ). These fees are hated an the nreliminary information availahle and are nn1v an estimate Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7/I/13, FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (j)Reg. 0 OT O.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:(j) Reg. ® OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXC $0.00 AGtJi2iniVr afive Fee: 0 Work Without Permit? 0 Yes •) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure G i T rcal>el Documentation fees: Strong Motion Fee: $0.00 1 # $859.00 Revisions IREVCOMTI ` Tenant Improvement Bldg Stds Commission Fee: $0.00 I7BT0®LsrTE.s $0.00 $859.00 _ 859.00 Revised: 07/02/2015 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C O P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST A JOB ADDRESS: �, 3 % X - PERMIT # 6 00 J� OWNER'S NAME: / j'e*/!f- PHONE # GENERAL CONTRACTOR: ' USINESS LICENSE # 1-76 R-7 jCV0 !%/L ,eG j� ITY/ZIPCODE: , *Our municipal code requires all businesses wolki g in the cV6 have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabin is &'A—ill—work' f Cement Finishing e— 7 Electrical C T& Excavation A j 1A Fencing iU Flooring / Carpeting t} Linoleum / Wood /v A Glass / Glazing ►-s A Heating l/Z. !g, tt Zic' Insulation lnfffids-api"g —,7 Masonry Painting / Wallpaper 2.9 2 �_ Paving /U Plastering ►-' J� Plumbing s$pG (A _rk- aw m Roofing IR3cso Septic Tank Sheet Metal Sheet Rock SQA Tile (Z £.Ci[ !j �� 7 L cS� a Owner /)Contractor Signature C? pq'-5-3 - %6 q � Z0 -Z3 I, Date rho K Building Department CITY OF CUPERTINO 10300 TORRE AVENUE + CUPERTINO, CA 95014-3255 TELEPHONE: (408) 777-3228 • FAX: (408) 777-7606 CUPERTINO I PG&E: REQUEST FOR GAS/ELECTRIC RELEASE TO: Pacific Gas & Electric—Service Planning Department Email: PGESouthernAgencylnspectionsgpgecom FAX: (800) 700-5722 FROM: City of Cupertino — Building Department PH: (408) 777-3228 FAX: (408) 777-7606 DATE: 10/5/2015 OWNERS NAME: MAIN STREET CUPERTINO AGGREGATOR BUILDING ADDRESS: 19399 STEVENS CREEK BLV® Unit LYFE KITCHEN ROSEBOWL: RM # METER # DESCRIPTION: USE: Commercial X Industrial Residential Apartment Bldg Meter Location From Street: Front Rear Center Left Side Right Side GAS RELEASE: ELECTRIC RELEASE: New Service: BTU'S: New Service: X Amps: Service Change: BTU'S: Service Change: _ Amps: Temporary Gas Release: Number of Meters: Notes: BUILDING INSPECTION DEPARTMENT: Inspector: GARY STREAM Sent by: PAT Temporary Power: (At New Meter Location) Temporary Power Pole: Amps: Temporary Power: Amps: (Reconstruction after Fire or Flood Damage) Number of Meters: Permit No: 15020045 Date/Time: 10/5/2015 CUPERTINO TEMPORARY CERTIFICATE OF OCCUPANCY FORM / t COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION Ir (� ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL ' 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 3y (408) 777-3228 • FAX (408) 777-3333 • building(a.cupertino.org ~ APN j I� AMOUNT (1% VALUATION[BLDBONDS] 3 j d BP #: DA J z _ � PROJECT VALUATION: SITEV ADDRESS: �TZr U�Ct3-� S � �jL?il' . �►-i� � 1ICq • OWNER'S NAME: C� � C �� ... ,....... ...................... ........... Date:...................... PHONE #: FAX #: t er: Signature:.......... 6 ..................................... Date: "�5�.... MAILING ADDRESS (if different from site address): APPROVED WITH CONDITIONS't'1 CONTRACTOR: t� D RV PHONE #: FAX #: '7 Z c c� CONTACT: ,� ti 1O �� L PHONE #: FAX #: P DSI .- 5 3 t/ �^ TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION[BLDBONDS] 3 j d CODE El CHECK El CASH BOND OF BOND: 5K min -10K max EDITION: TCO EXPIRATIONFEE: APPROVED WITH CONDITIONS" $286.00/1110 o O ] TOTAL FEE: $ eL [1TEMPOCC �(L` - DATE (6 MONTHS MAX): El APPROVED WITH CONDITIONS - Signature: .......... ... ,....... ...................... ........... Date:...................... USE TYPE OF CONSTR FLOOR AREA OCC LOAD LEVEL COMMENT ❑ APPROVED APPROVED WITH CONDITIONS" Public WOrks ❑APPROVED El APPROVED WITH CONDITIONS - Signature: .......... ... ,....... ...................... ........... Date:...................... t er: Signature:.......... 6 ..................................... Date: "�5�.... ❑ APPROVED APPROVED WITH CONDITIONS't'1 OTHER DEPARTMENT / AGENCY APPROVALS: Planning Signature: ............................................ ........... Date:........................ ❑ APPROVED 1:1 APPROVED WITH CONDITIONS' Fire Signature:.. ... (( ..... ... ... .. ... ........... Date:.71�J.��?(IR• ❑ APPROVED APPROVED WITH CONDITIONS" Public WOrks ❑APPROVED El APPROVED WITH CONDITIONS - Signature: .......... ... ,....... ...................... ........... Date:...................... t er: Signature:.......... 6 ..................................... Date: "�5�.... ❑ APPROVED APPROVED WITH CONDITIONS't'1 *CONDITIONS OF COMPLETION - Attach a letter signed by the contractor and owner of the property stating the list of items required to be completed for each individual Department before final occupancy can be granted. Include approximate completion dates for each item. The undersigned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or buildings complete and in compliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration date specified. If this Temporary Certificate of Occupancy expires, the total amount nd may be forfeited and the non-compliance may result in force ent action. Owner ? Cont ct Signature: ...... ............. Date:Signature:....................................................... Date:.. Z:.Le. This temporary certificate ensures that all fire protection and life safety systems have been completed, inspected, successfully tested and approved for the specific area of the building specified above to provide a reasonable degree of safety to the occupants from fire and similar emergencies. BuildingOfficial: ...................................................................... Print: ......................................................................... Date:.............................. DEPARTMENT ACTION: After determination, copies to: 1) applicant, 2) permit file TempOccForm_2013.doc revised 717114 ..44, PERMIT FEE RECEIPT Case # 15020045 Date Printed: 02/25/2016 CUPER71N0 CITY OF CUPERTINO - FEES RECEIPT Case Number: 15020045 Permit No: 15020045 Project Valuation: 835000.00 Date Submitted: 02/09/2015 Permit Type: 1A TI Address/APN: 19399 STEVENS CREEK BLVD (316 20 112) Receipt #: 201734 Scope of Work: LYFE KITCHEN,COMM.T.I ON(E)SHELL BUILDING 4,092 SQ Payment Date FT REV # 1 - ROOF TOP EQUIPMENT DETAILS, ADD OUTLET & KITCHEN EQUIPMENT CHANGES - ISSUED 2/23/2016 Contacts Contact Type: Applicant Full Name: MAIN STREET CUPERTINO AGGREGATOR Primary Phone: (916) 503-1073 Address: 2882 SAND HILL RD STE 241 MENLO PARK, C. Email: mrohde@vallcoshoppingmall.com Fee Information Amount' Building - Bond TCO GOOD TILL 312512016 $8,350.00 Temporary Occupancy TCO GOOD TILL 312512016 $286.00 Payment Information Payment Date Patron Payment Type Amount Building - Bond 02/25/2016 DR NICHOLS Credit Card $8,350.00 Temporary Occupancy 02/25/2016 DR NICHOLS Credit Card $286.00 FEE TOTAL $8,636.00 AMOUNT PAID $8,636.00 BALANCE DUE $0.00 02125/2016 - 3:00:44 PM - Generated by: paulos 1/1 d� i Information F L C =zM .ToBuild On e Co • ibstlno ��dZ-o6 Professional service :rxlustries knc. 4703 Tidewater Ave. suite B G� Oakland. CA CA 1 ✓ v Phone: (510) 434-9200 Fax: (510) 434.7676 V --J Steel Observation Report Report No: SIF:0587162-4 Issue No: t Client: PARKWAY CONSTRUCTION & CC: 'nmaa m" m..a tom m" toThe spea"t mc"m" mm mamma MGM and may rot mr.a.n " WWWcatic u a snarabors. Thu moan n�a, as be ASSOCIATES INC. mob• aseW In M..wma � Parnaaslor w PialasmorW S.rvlo 1000 CIVIC CIRCLE l 1 r� a0,rwm". - anW"raw togo"Ussvw e '�"~,'"e .«,�,,, mpdtb ro pManes Wpcm rm prood. the mokann is W" Iha PSI LEWISVILLE,TX 75067( S R C. Project: PC,LYFE KITCHEN, CUPERTINO,CA C Ci CUPERTINO, CA 'flet °""'°''' "° C sir ;l tylia: aM1+=:115 General Details Date: 9/5/2015 Technician: Albert George General Contractor: Subcontractor: AireStream Mechanical Weather: Warm Location(s)/ltem(s): Hood Exhaust Ducting Type(s) of Observation Performed & General Checklist Q Smdal Inspection ❑ AWSQWASNT VT Q At Completion ❑� In Progress ❑ Post-cor�- Q New Irispecbm ❑ Re -Inspection ❑ Continuous ❑ Periodic ❑ Other structural We" Structural Bottling Steel Ersn:tlon Post -Installed Anchors Opal Web Steel Joist Inspection ❑ ShW 0 t'leld ❑ Ratension ❑ Brg ❑ ShW ❑ Field ❑ Chemlol ❑ Necharkii! ❑ Shop ❑ Field Weld Process Ic Boils Specilled Joint Details ,CBO Report No Joist Gkder seat Connactiom Electrode Tum•ot•Nut Erection Dwqs Anchor Type Joist Seat Corrections Wald Profiles(s) Cal. Wrench inspectim Rpt5 Adhsslve lype Horiz. Brkig ng Connections Welder Cart(s)Tension Control Mark No s Hole Diameter X• Connections Weld Prt Anchor Bots Embed Wind Brace Connections Min ceraHardened washers Columns Mand, Inapuq's Bottom Girder &aces Prop a Tighten Beams Clean d RTU Joist Rekdorcemerd Preheat Fa Surfaces Metal Deck/Studs to Adhes. Li UT Skldmore Tests x•& ht Box Definitions: X=Attached; C --In Compliance; NA -W Applicable: NC=NnmconWrnance (see below). 'Describe Llmitatbns Below or Coned Bide Dept. Detailed Observations, Materials, Workmanship do Procedure Descriptions Referenced Details/Drawings: Non -Conformance #: Parties Notified: ❑ General Contractor ❑ Subcontractor ❑ Archited ❑ Engineer ❑ Owner ❑ Other: To the best of my knowledge, the work inspected above was In accordance with the bulldhV deparunant approved design drawings, specilications and applicaWe workmanship provisions of the international Building Code: ❑ &per AS Noted ❑ Not Applimble ❑ Unapproved DrawhVs/Pl&WMaterial5 ❑ NCR Leered ❑ Non-Compkance ❑ Requires Engineers Acus kmce (RFI) ❑ Reinspe bm Required Standby Time: Inspector: Albert George ID Number: 5055979 Remarks 1: Observed and inspected the completed welds for Hood Exhaust Ducting for two hoods _ 2: Light tested the completed welds and rewelded any problem areas. Weld+ng per specs and plan details on M401, dated 4/10/15 by AireStream Mechanical. 3: Access doors are added for clean outs .Hood Ducting is ready for insulation wrappings 0 2000.2015 OESTLab ny SDecnreOEST.Corr Paye 1 of 1 kill" SUB �Z AL STATEMENT OF SPECIAL INSPECTIONS, 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E , C.B.O., BUILDING OFFICIAL r CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 COPY (408) 7773228 • FAX (408) 777-3333 • buildina@cupeTtino.org SITE ADDRESS l 3 �tR Si�JS WE0.(, tit m.. . APN asp t j o2 p4 c4 lei .. Conlractor.w.�"-..�'� Address..„ �' ..!3'i ff ..................................'.... ..�r�.�..t� Address I .(? a, :, ............................. •• .°,.. .. CiRyt3t.., . ..�.. ��:,,(...,....°..2�►..��'..r.�..Ptrarta`t' . Apptcant.. t� :..L :».......... ............ ......................... ............. Engtneer/Architect..t'�`4ik1 A...,1....£���1� fS. ����.5.btyti..)JN� Address..titi ; f<S. an'_( r Address �f ?? v'4 t �...x... +' , is D,{,4 J . Z ClryfSt.is r': } 1. T1 ..........Zip.. Phone r`��2 Ciiy/St. tSr T:�5`'i l x. Phwre2t t 4»?•. .lt ...............Zip PROJECT DESCRIPTION: ti This 'STATEMENT OF SPECIAL INSPECTIONS' is submitted In fulfillment of the requirements of CBC Sections 1704 and 1705. This fort is structured after and used by permission from the Structural Engineer Association of Northern C, 1 fornia's (SEAONC) mode statement of Special Inspections. Alan, Included with this form is the following: ❑ `LIST OF SPECIAL INSPECTION AGENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the tests and inspections for this project 'SCHEDULE OF SPECIAL INSPECTION' (page 3 —B), The Schedule of Special Inspections summarizes the Special Inspections and tests required. Special Inspectors will refer to the approved plans and specifications for detailed special Inspection requirements. Any additional tests and inspections required by the approved plaits and specifications shall also be performed. Special Inspections and Testing will be performed in accordance with the approved pians and specifications, this statement and CBC Sections 1704, 1705, 1706, 1707, and 1708. Interim reports will be submitted to the Building Official and the Registered Design Professional in Responsible Charge in accordance with CBC Section 1704.1.2. A Final Report of Special Inspections documenting required Special Inspections, testing and correction of any discrepancies noted In the inspections shall be submitted prior to issuance of a Certificate of Use and Occupancy (Section 1704.1.tiis Ftnat1. document: _A D • Required special inspections. • Correction of discrepancies noted In inspections. APR The Owner recognizes his or her obligation to ensure that the construction complies with the ailiproved permit documents and to- implement this program of special inspections. In partial fulfillment of these obligations, the O er will retain and directly pay for the Special Inspections as required in C8C Section 1704.1. !, This plan has been developed with the understanding that the Building Official will:m • Review and approve the qualifIcetions of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their duties as called for in this Statement of Special Inspection. • Review submitted inspection reports. • Perfarm inspections as required by the local building code. Specia/nrpecrionForm 2012.doe revised 09/06/12 LIST OF SPECIAL INSPECTION AGENCIES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre -approved and listed an Cupertino's approved Special Inspector's list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order" and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow two weeks to complete the application process. The following are the testinq and s ecial inspection agencies that will be retained to conduct tests and inspection on thisproject: EXPERTISE FIRM I INSPECTOR INFORMATION 1. Special Inspection (except for ... ......... ........ ............... geotechnical) city r.,i,.eriaore.................Zip .sa5.5a........... Telephone..925.-606.7.00................. Fax.........9..2.5..-.6..0.6..-.7.7..0..2............. Email ............m.................pe.c..o..mo..... ............... 2. Material Testing Firm M.asxtscaoe..Fnsi D.eRsins..L.?tPaa K.vxa4 ,...TsAddr-.6zaa Pres[oa Ave........................................................... City Livec,p�re... ...... ... . State ...... A ..Zip .....99551 Telephone.9zs sos-.?�oo. Fax ........ 9z5.,6Pg.::,,o? Email.....anamay, acr y yke.: 9 ............... 3. Geotechnical Inspections Firm.....................................................................Addr......................................................................................... City-- .......................................... ...... ...... --11 ........................................ State ......................Zip ..,....... - ... ,...... Telephone.. ..... ___ ... .............. .... .. Fax....,....................................... Email......................,.................................. 4. Other. Finn..... . ................... ............................................ Addr...................................... ....... ....,.................................... -.. City.......................................................................................................... State ................... _-Zip ...................... Telephone...................................... Fax .......,........ ........ ____ ......... Email.. ........... ,....... ..... ___ ._............ ........ 'All agencies specified on this form must be pre -approved and listed on the City of Cupertino's Approved Special Inspector's List SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Secfion 1705.3: N The extent of the seismic -force -resisting system is defined in more detail in the construction documents. WIND REQUIREMENTS Section 1706.4.1 Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForm_2012.doc revised 09106112 Sequence of Operation for FP Electrical Pa"ckag"es"' with ECPM03 Circuit Boards m5 _06 ,r��11�i��°Once all required connections have been completed as indicatd,on the schematic, power can be two applied to the panel. The ECPM03 Circuit Board and LCD screen will power up and beep. • The LCD Screen (CASHMI) has 4 buttons with the function displayed adjacent to the button. Typically, LIGHTS and FANS are shown on the bottom 2 buttons. An empty box around FANS or LIGHTS means that these are OFF. A dark box around the FANS or LIGHTS means that these are turned ON. • A thermistor will be installed in every hood exhaust riser. A 2 -wire plenum rated thermistor cable (18 gauge typical), run in conduit, should be used to wire the sensors back to the controller. • A room temperature sensor is provided with the panel and should be installed in a safe location, free of influence from external heat sources. It should be indicative of the average temperature away from the appliances. • When the hood system includes make up air, the control panel automatically starts and operates the make up air fan simultaneously with the exhaust fans. This function allows the system to meet the requirements of IMC section 508.1. • Sequence of Operation: Method One o Fans On: Press the FANS button to energize the fans. This will automatically turn on the LIGHTS as well. LIGHTS can be turned ON and OFF manually by pressing the LIGHTS button. o Fans Off: At the end of the day after cooking is completed, the staff can press the FANS button at the CASHMI to turn the fans and lights off. The fans will not turn off if the appliances are still hot; reference automatic operation. • Sequence of Operation: Method Two (PREFERRED) o Fans On: Turn on the cooking appliances and allow them to reach idle temperature. The fans should automatically be energized as the cooking appliances heat up. The factory set activation point for duct temperature override of the fan switch is 10 degrees above kitchen room temperature. This function allows the system to meet the requirements of lrx. IMC 507.2.1.1, which require exhaust fans to activate when cooking is occurring. LIGHTS will automatically be turned on as well. LIGHTS can be turned ON and OFF manually by pressing the LIGHTS button. r> o Fans Off: If the system was in automatic operation, the FANS will turn off when the duct temperature goes below the activation point minus the temperature hysteresis of 2 degrees. For example, if the activation temperature is at 85 degrees F and the VA temperature hysteresis is set to 2 degrees F, then the fans will turn off at 83 degrees F. NOTE: The hysteresis timer, factory set at 30 minutes, is used to prevent the fans from cycling on and off too often due to small appliances generating just enough heat to turn on the fans but not enough to keep them ON for a long time. The Hysteresis Timer will maintain the fans on after they have been activated by temperature for a minimum time w set by this timer, even if the temperature in the duct cools back down. SUBMITTAL #2 F 't r y. 2013-07-02� �r 2 AL Mr. Scott Smith Ovention Inc. 10500 Metric Dr., Suite 128 Dallas, TX 75243 United States E-mail: ssmith@applianceinnovation.com Our Reference: File E351658, Project 12CA22770 @UL APR sa z015 Subject: E351658 - EPA 202 EVALUATION OF CONVECTION OVEN "MATCHBOX", MODELS M1313 AND M1718. Mr. Smith: Per your request, Project 12CA22770 was opened for the evaluation of grease -laden vapors produced by the Models M1313 and M1718. The model M1718 was used for test purposes, and considered representative of all other models. The scope of the project was to test this model in accordance with EPA Method 202 test guidelines to demonstrate compliance with NFPA96, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, paragraph 4.1.1.2 conducted in accordance with UL710B, the Standard for Recirculating Systems, Sec. 17 for Complimentary Listing under UL's KNLZ category. The test was conducted at our facility in Northbrook, IL on May 14`h 2012. This letter will report the results of the EPA202 test. For the record, the test was conducted on the Model M1718 conveyor oven "Matchbox", cooking 12 in. pepperoni pizzas (Tombstone, with 19 pepperonis per pizza) as specified in Appendix A. Please seethe attached page (Appendix A) for the test method and results of the tests. The results are considered to comply with UL710B, Section 17 and NFPA96, paragraph 4.1.1.2 since the measured values were less than the 5-mg/m3 limit. Should you have any questions or comments concerning the above, please feel free to contact the undersigned. Any information and documentation involving UL Mark services are provided on behalf of UL LLC4 a�authorized licensee of UL. y •_- (n Sincerely, & Bill Morler Sr. Project Engineer Tel: 847-664-1852 E-mail: William.Morler@ul.com UL LLC 333 Pfingsten Road, Northbrook, IL 60062-2096 USA T: 847.272.8800 / F: 847.272.8129 /W: UL.com Reviewed by: Fred Zaplatosch Sr. Staff Engineer E-mail: fred.zaplatosch@ul.com TA7 y A n N 2 20 Page 1G-02 :4% FN' APPENDIX: A UL TEST FOR EVOLUTION OF SMOKE OR GREASE -LADEN AIR: The Appliance Innovation Inc. Model M1718 conveyor oven was tested using the method derived from EPA Method 202. A 12 in. by 6 in. rectangular, 108 in. tall sheet metal stack was constructed on top of a sheet metal hood and mounted above the exhaust vent of the induction cooker. A sampling port was located approximately 80 in. downstream from the hood exhaust, at which point it was determined there was laminar flow. The hood exhaust was maintained at 500 CFM throughout the duration of testing. The sampler was assembled and an out of stack filter was used. A pre -leak check was conducted and determined to be < 0.02 ft/min. Sampling was done at 8 traverse points. The oven with integral system was operated normally by cooking the following foods: 12 in. pepperoni pizza (Tombstone, with 19 pepperonis per pizza), each cooked for 3 minutes with 0 seconds between loads for 8 hours (total of 160 pizzas). Oven was set to maintain 525 OF During the cooking operation, it was noted whether or not visible effluents evolved from the air exhaust of the hood. Gauge, meter and temperature readings were taken and recorded every 10 min. After cooking, the condition of the duct was noted and a post -leak check was conducted and determined to be < 0.02 ft3/min. After being allowed to cool, the sampling equipment was disassembled; the filter was removed, and placed into a sample container labeled No. 1. The liquid in impingers Nos. 1, 2, and 3 were volumetrically measured and transferred to sample container No. 3. The silica gel and impinger No. 4 was transferred to sample container No. 5. The nozzle, probe and impingers were rinsed three times with water and the rinse was added to container No. 3. These parts were also rinsed three times with acetone and transferred to container No. 4. All additional inter surfaces of the sampling terrain glassware were rinsed with methylene chloride three times; the rinse was transferred to container No. 6. A blank of acetone approximately equivalent to the amount used for rinses was aliquoted into container No. 2, the same was done for the distilled de -ionized water and methylene chloride except that these were aliquoted into their own individual containers labeled No. 7 and 8 respectively. All containers were properly labeled and sealed, then the liquid levels in all the containers were marked. The analysis phase was done in accordance with EPA Method 202, using the out of stack filter. RESULTS: There was no visible smoke emitted from the exhaust of the hood during the normal cooking operation of the Model M1718. There was no noticeable amount of smoke accumulated in the test room after 8 hours of continuous cooking. The total amount of grease -laden effluents collected by the sampling equipment for the Model M1718 was found to be 0.49 mg/m3, which is less than 5 mg/m3 limit. UL LLC 333 Pfingsten Road, Northbrook, IL 60062-2096 USA T: 847.272.8800/ F: 847.272.8129/W: U L.com Page 2 of 2 or 2013-12-27 RECEIVED Mr. Scott Smith Appliance Innovation Inc. S >t O A A a 10500 Metric Dr. ALEAF, IaC°'� Dallas, TX 75243 �C �� United States 77 z E-mail: ssmith@applianceinnovation.com Reference: File: SV29641 Project : 4786088070 P.O. Number: 83305 Product: EPA 202 TEST METHOD: USING THE MODEL M1718 COOKING THE BELOW FOOD PRODUCTS AS MEDIA. Dear Mr. Smith, Per your request, project 4786088070 was opened for the evaluation of grease -laden vapors produced from cooking un -fried chicken, sweet fries, Gardein frozen potatoes, flat bread, and vegetables in the model M1718 convection oven. The scope of this project was to determine the total grease emissions from cooking Lyfe Kitchens specified food load as noted in Appendix A. Testing is conducted in accordance with EPA Method 202 test guidelines to determine ultimate results. Results are used to determine compliance with Section 17 of UL710B, the Standard for Recirculating Systems, formerly Section 14 of UL 197, Eighth Edition, Supplement SB, and paragraph 4.1.1.2 of NFPA96, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. The test was conducted at our facility in Northbrook, IL on December 18`h, 2013. This letter will report the results of the EPA202 test. For the record, the test was conducted using an Appliance Innovation convection oven, Model M1718. The test media was as noted in the table below as specified by Appliance Innovation as shown in Appendix A. The results are considered to comply with UL710B, Section 17, formerly Section 14 of UL 197, Eighth Edition, Supplement SB, and NFPA96, paragraph 4.1.1.2 when tested with your specified food load and requested cook times since the total amount of grease -laden effluents collected was 1.71 mg/m', which is less than 5 mg/m' limit. No evaluation was conducted in regards to fire protection. In addition, no evaluation of the conveyor oven itself was conducted. 0� i41 24 BY 1 of 18 V. UL LLC did not select the samples, determine whether the samples were representative of production samples or witness the production of the test samples, nor were we provided with information relative to the formulation or identification of component materials used in the test samples. The test results apply only to the actual samples tested. The issuance of this report in no way implies Listing, Classification or Recognition by UL LLC and does not authorize the use of UL Listing, Classification or Recognition Marks or any other reference to UL LLC on the product or system. UL LLC authorizes the above named company to reproduce this Report provided it is reproduced in its entirety. The name, Brand or Marks of UL LLC cannot be used in any packaging, advertising, promotion or marketing relating to the data in this Report, without UL's prior written permission. UL, its employees and agents shall not be responsible to anyone for the use or nonuse of the information contained in this Report, and shall not incur any obligation or liability for damages, including consequential damages, arising out of or in connection with the use of, or inability to use, the information contained in this Report. This letter will serve to report that all tests on the subject product have been completed. All information generated will be retained for future use. This concludes all work associated with Project 4786088070 and we are therefore closing this project. Our Accounting Department has been instructed to bill you for all charges incurred. Thank you for the opportunity to provide your company with these services. Please do not hesitate to contact us if you should have any questions or comments. Very truly yours, Bill Morler Sr. Project Engineer Department: 3015GNBK Tel: 847-664-1852 Fax: 847-407-1852 E-mail: William.Morler@ul.com Reviewed by: Fred Zaplatosch Sr. Staff Engineer Department: 3015GNBK E-mail: fred.zaplatosch@ul.com 2of18 APPENDIX: A CLIENT INFORMATION Company Name APPLIANCE SCIENTIFIC INC Address Suite 128 10500 Metric Dr Dallas, TX 75243 AUDIT INFORMATION: TESTS TO BE CONDUCTED: Test No. Description of Tests Per UL 710B Edition/Rev 2" 2011-09-02 Standard CSA C22.2 No. 109 ision Date No. CSA C22.2 No. 109 2 ----F2013/12/17 2013/12/17 M1981 R2009 [X] Tests Conducted by+ Leo Carrillo/Dennis DeFord Printed Name Signature UL Staff supervising UL Staff in training Printed Name Signature Reviewed and accepted by William G. Morler ht.J + &. qualified Project Handler r Printed Name Signature Special Instructions - [ ] Unless specified otherwise in the individual Methods, the tests shall be conducted under the following ambient conditions. Confirmation of these conditions shall be recorded at the time the test is conducted. Ambient Relative Barometric Temperature, C t Humidity, % t Pressure, mBar t [X] No general environmental conditions are specified in the Standard(s) or have been identified that could affect the test results or measurements. RISK ANALYSIS RELATED TO TESTING PERFORMANCE: The following types of risks have been identified. Take necessary precautions. This list is not all inclusive X Electric shock TESTS TO BE CONDUCTED: Test No. Start Done Test Name 0 Comments/Parameters Tests Conducted b ++ 1 2013/12/13 2013-12-17 POWER INPUT TEST: RATING CSA 22.2 109-M1981 : 2 ----F2013/12/17 2013/12/17 2013/12/23 CAPTURE TEST: F3 2013/12/23 EMISSION TEST: Special Instructions - [ ] Unless specified otherwise in the individual Methods, the tests shall be conducted under the following ambient conditions. Confirmation of these conditions shall be recorded at the time the test is conducted. Ambient Relative Barometric Temperature, C t Humidity, % t Pressure, mBar t [X] No general environmental conditions are specified in the Standard(s) or have been identified that could affect the test results or measurements. RISK ANALYSIS RELATED TO TESTING PERFORMANCE: The following types of risks have been identified. Take necessary precautions. This list is not all inclusive X Electric shock r I Radiation Energy related hazards Chemical hazards Fire Noise Heat related hazards Vibration [ ] Mechanical [ ] Other (Specify)_ 3of18 01 TEST LOCATION: (To be completed by Staff Conducting the Testing) [X]UL or Affiliate OWTDP OCTDP OTPTDP OTCP OPPP DWMT OTMP OSMT Company Name: UL/NBK TEST EQUIPMENT INFORMATION [X] UL test equipment information is recorded on Meter Use in UL's Laboratory Project Management (LPM) database. Inst. ID No. Instrument Type Test Number +, Test Title or Conditioning Function/R ane Last Cal. Next Cal. Date Date The following additional information is required when using client's or rented equipment, or when a UL ID Number for an instrument number is not used. The Inst. ID No. below corresponds to the Inst. ID No. above. Inst. ID No. Make/Model/Serial Number/Asset No. FEST SAMPLE IDENTIFICATION: The table below is provided to establish correlation of sample numbers to specific product related information. Refer to this table when a test identifies a test sample by "Sample No." only. Sample Card a Test Sample No. Date Received No.+ No. Manufacturer, Product Identification and Ratings 1729873 2013/10/02 ALL 1 Ovention, Model M1718 rated 240 V, 49 A. 1778852 2013/12/11 3 2 Trays D Sampling Procedure - This document contains data using color and if printed, should be printed in color to retain legibility and the information represented by the color. + - If Test Number is used, the Test Number must be identified on the data sheet pages or on the Data Sheet Package cover page. 4of18 POWER INPUT TEST: UL 7106 Sec. 44 (6.2) RATING (CSA 22.2 109-M1981): METHOD The supply voltage was adjusted to voltage and frequency as noted in "General Test Considerations", 240 V, 60 Hz. Test to determine proper test voltage for c -UL testing [X] The supply voltage was adjusted to the increased test voltage as noted below. Following the test at increased test voltage, the supply voltage was adjusted to the value necessary to cause the appliance to draw the increased test current, calculated as specified below. Increased Test Voltage (Vt): 125V for appliances rated between 110V -125V. 216V for appliances rated 208V. 250V for appliances rated between 220V-25OV. Increased Test Current (It): Ir(Vt/Vr) = 53.2 A Increased Test Power (Wt): Wr(VtNr)2 = (W)(kW) Where Vr, Ir, and Wr, are the rated voltage, current, and power of the appliance, respectively. Note: when the appliance is rated for a range of voltages, the mean of the range is to be used as Vr. PARAMETERS Appliance Ratings: Volts: 240 ; Current: 49 A; Power: (W) 01 5of18 POWER INPUT TEST (CONT'D) RATING (CSA 22.2 109-M1981): RESULTS UL 710B Sec. 44 (6.2) (D] Operating Conditions Specified Measured Volts, Ams Power, 1-1-1-2 L1 L2 k Volts, Ams Power, 1-1-1-2 L1 I L2 Full power operation, rated voltage 240 --- --- --- 240 40.1 8450 X Full power operation, rated current --- 49 --- Full power operation, rated power --- --- --- Full power operation, V --- --- --- c-UL Test Conditions Full power operation, increased test voltage 250 --- --- --- 250 41.2 9057 [X] Full power operation, increased test current --- 53.2 --- [ ] Full power operation, increased test ower --- --- --- [X] The input current [was] [was4xA] between 90% and 105% of the rated input current when the appliance was energized at rated voltage. [ ] The input power [was] [was not] between 90% and 105% of the rated input power when the appliance was energized at rated voltage. [ ] The input current [was] [was not] over A when the appliance was energized at V. (Note: see paragraph 47.3 of UL 197) [ ] The input current [was] [was not] over A when the appliance was energized at rated wattage. (Note: see paragraph 47.3 of UL 197) Note: Per William Morler the input test was only conducted at 240V/25OV. L.0 2013-12-19 6of18 01 CAPTURE TEST: UL 7108 Sec. 58 Also reference UL 710 Sec. 31 METHOD The model M1718 cooking appliance was placed under a hood, located in a draft free room and is operated at the lower air flow limit. Food product as specified below was then used for testing, see Emission Testing for specific details. The cooking area is to be observed for the presence of visible smoke and grease -laden air, and the hood assembly shall completely capture all of the emission as determined by observation. The test shall be conducted by loading the maximum amount of the food products noted below, on or in the cooking appliance and cooking the food product until it is overcooked (very well done) as follows. The cooking cycle is to be repeated at least once. a. Deep fat fryers are to be tested with fries, b. Pressure deep fat fryers are to be tested with chicken pieces, c. Griddles, broilers and similar appliances are to be tested with meat cakes, d. Ovens, roasters and similar appliances are to be tested roasting chickens, and e. Other appliances are to be tested using the food product(s) for which they are designed. When one of the appliances specified in (a) - (d) is not intended for cooking the specified food (for example, donut fryers), the appliance is to be tested using the food product for which the appliance is designed. When the device and cooking process do not produce visible cooking smoke and grease laden air, a smoke generator is to be used and positioned in the cooking area to establish a more visible means for conducting this test. COOKING PRODUCT [X] Other - 7of18 Product FOOD # of Individual Cook Time Oven Setting Weight of Product # of bags Temp 'F Cycles (min) per cycle before (Oz) cooking Un -fried Chicken 10 3:30 Chicken(2) 10.976 1 30 Fries 2 3:30 Sweet Fries 26.432 1 30 Potatoes 2 3:00 Gardein Frozen 51.392 1 30 Flatbread 4 1:30 Flat Bread 8.608 1 30 2 3:00 Veggies with 12.192 1 30 Veggies onions added 7of18 RESULTS Their [was] [was not] the presence of visible smoke and grease -laden air from the appliance during testing. The sample [did] [dkknet] capture all of the emissions from the cooking appliance. The appliance is to be observed for the presence of visible smoke and grease laden air escaping from the hood assembly through the discharge port or through external seams, joints, penetrations, and that portion of the hood that captures grease laden vapors. 8of18 EMISSION TEST: UL 7108 Sec. 59 METHOD TEST FOR EVOLUTION OF SMOKE OR GREASE -LADEN AIR: The model M1718 conveyor oven was placed under a hood operating at 500 CFM, and is tested using a method derived from EPA Method 202. The manufacturer also provided the product as noted below for the test. A 12 in. by 6 in. rectangular, 108 in. tall sheet metal stack was constructed on top of the hood and mounted above the exhaust vent of the hood. A sampling port was located approximately 80 in. downstream from the hood exhaust, at which point it was determined there was laminar flow. The sampler was assembled and an out of stack filter was used. A pre -leak check was conducted and determined to be < 0.02 ft/min. Sampling was determined to be done at 8 traverse points. The oven was operated normally by cooking the following foods: One Complete Cycle The cooking cycle was repeated for 8 hours of continuous cooking. This resulted in complete cycles. "' - Completed Food Loads were as follow: 16 Sweet fries bags 16 Potatoes bags 16 Steak set up bags 30 Flat bread 79 Chicken bags 9of18 Weight of Product FOOD # of Individual Cook Time Oven Setting Product # of bags Temp °F Cycles (min) per cycle before (Oz) cooking Chicken 10 3:30 Un -fried Chicken 10.976 1 30 Fries 2 3:30 Sweet Fries 26.432 1 30 Potatoes 2 3:00 Gardein Frozen 51.392 1 30 Flatbread 4 1:30 Flat Bread 8.608 1 30 2 3:00 Veggies 12.192 1 30 Veggies with onions added The cooking cycle was repeated for 8 hours of continuous cooking. This resulted in complete cycles. "' - Completed Food Loads were as follow: 16 Sweet fries bags 16 Potatoes bags 16 Steak set up bags 30 Flat bread 79 Chicken bags 9of18 Food Preparation Procedure Unfried chickens; 2 parts unfried per ziplock bag -cook on Unfried Chicken setting -spray both sides of the parts unfried with pan spray (about 4 sec. per side, very evenly coated) -cook on Unfried Chicken setting Sweet potato fries; each bag contains 4 individual portions -spread each bag of fries across a parchment lined half sheet pan in a single layer -cook as is on sweet fries setting Roasted potatoes; each bag contains 9 servings of potatoes -spread each bag of roasted potatoes across a parchment lined 1/2 sheet tray -cook on Veggies setting Flatbreads; -assemble flatbreads; per crust you will need in this order... spread 1 oz. pomodoro sauce sprinkle 1/4 c mozzarella balls sprinkle 1/4 c cherry tomatoes sprinkle 1/4 c pizza cheese -to cook, place flatbreads directly on oven rack and cook on Flatbread setting Roasted veggie/steak set-ups; each bag will contain 1 portion -place each veg set-up on a sheet pan, we use mini sheet pans for heating individual portions, but cooking on a 1/2 sheet pan should suffice for this test, if none are available -lightly spray each veg set-up with a light coating of spray oil -cook on Veggies setting During the cooking operation, it was noted whether or not visible effluents evolved from the air exhaust of the hood. Gauge, meter and temperature readings were taken and recorded every 10 min. After cooking, the condition of the duct was noted and a post -leak check was conducted and determined to be < 0.02 ft'/min. 10 of 18 EMISSION TEST: (CONTD) UL 7106 Sec. 59 After being allowed to cool, the sampling equipment was disassembled. The glass -filter is to be removed using a pair of forceps and placed in a clean petri dish. The dish is to be sealed and labeled "sample 1". A sample of the acetone of the same volume that will be used to rinse -out the nozzle and probe is to be placed into a clean sample bottle, sealed, and labeled "sample 2". The level of the liquid in the sample bottle is to be recorded. The inside of the nozzle and probe is to be rinsed with acetone taking care to collect all the rinse material in a clean sample bottle. The sample bottle is to be sealed, labeled "sample 3", and the level of the liquid in the bottle is to be recorded. The liquid in the first three impingers is to be measured and the total volume is to be recorded which will be compared to the original volume. The liquid is to be quantitatively transferred to a clean sample bottle. Each impinger and the connecting glassware including the probe extension are to be rinsed twice with water. The rinse water is to be collected and added to the same sample bottle. The sample bottle is to be sealed, labeled "sample 4" and the level of the liquid in the bottle is to be recorded. This rinse process is to be repeated with two rinses of methylene chloride (MeC12). The rinses are to be recovered in a clean sample bottle. The sample bottle is to be sealed, labeled "sample 5" and the level of the liquid in the bottle is to be recorded. A volume of water approximately equivalent to the volume of water used to rinse and a volume of McC12 approximately equivalent to the volume of McC12 used to rinse is to be placed in two clean sample bottles. The sample bottles are to be sealed, labeled "sample 6" and "sample 7" respectively, and the level of the liquid in the bottles is to be recorded. The weight of the fourth impinger containing the silica gel is to be recorded and then the silica gel can be discarded. The analysis phase was done in accordance with EPA Method 202, using the out of stack filter RESULTS The results [are] [are RGt] considered acceptable because there [was] [was no] visible smoke emitted from the exhaust of the hood during the normal cooking operation. There [was] [was no] noticeable amounts of smoke accumulated in the test room after 8 hours of continuous cooking. The total amount of grease -laden effluents collected by the sampling equipment was found to be 1.71 mg/m', which is less than 5 mg/m'. The total grease emissions (per clause 78.2 of 71013) in pounds per hour per linear food of hood was 0.000540 Ib/hr/ft. 11 of 18 0 EMISSION TEST: (CONT'D) CONDENSIBLE MATTER (Lab Analysis) UL 710B Sec. 59 Sample Bottle No. Description Volume, ml Final Wt, mg 1 Filter Paper - 0.6075 2 Acetone Blank 34 1.0373 3 Acetone Wash 29 1.0109 4&5 Solvent Phase(Wash) 215 1.0870 4&5 Water Phase Wash 165 1.0829 6&7 Solvent Phase (Blank) 430 1.0777 6&7 Water Phase Blank 435 1.1033 Filter paperweight before test- 0.6018 mg Analysis 1. The liquid level of all the sample bottles is to be measured. 2. The filter from sample one is to be removed and dried to constant weight by means of a desiccator or an oven. The weight of the filter is to be recorded. 3. The volume of sample two is to be determined. The liquid is then to be transferred to a beaker and evaporated to dryness. The volume of the liquid and the final weight of the condensable matter are to be recorded. 4. The volume of sample three is to be determined. The liquid is then to be transferred to a beaker and evaporated to dryness. The volume of the liquid and the final weight of the condensable matter are to be recorded. 5. The volumes of sample four and five are to be measured. 6. Samples four and five are to be combined. The solvent phase is to be mixed, separated, and then repeated with two McC12 washes. 7. The solvent extracts obtained from the procedure in 6 are to be placed in a beaker and evaporated to a constant weight. The final weight is to be recorded. 8. The water phase is to be placed in a beaker and evaporated to dryness. The final weight is to be recorded. 9. The volumes of samples six and seven are to be determined. Sample bottles six and seven are to be analyzed according to procedures 8 and 7 respectively. 12 of 18 File: SV29641 Project: 147860782701 Date: 12/18/2013 Client: Appliance Innovation Model: Product Tested M1718 chicken, potatoes, flatbread, sweet fries 13 of 18 Project No. 4786078270 File: SV29641 Appliance Innovation Model: M1718 Calculations needed for Nozzle Size = 21 °C OH@ = 40.763 Number from most recent LEM calibration certificate • Oxygen = 20.85 %02 Oxygen inside stack during operation • Carbon %CO2 Carbon Dioxide inside stack during operation Stack Size 9.848 mm 6/16 in Temperature = 34.4 °C Temperature inside stack during operation Barametric Pressure = 739.14 mmHg Barametric pressure at location of meter Stack Static Pressure = 0.18 mm H2O Static Pressure inside of duct Average Square Enter pressure differential at each traverse point root AP = 1.641 AP mm H2O (inches H2O) Pressure CFM Pressure CFM Meter Temperature = 21 °C Pitot Tube 1. • Coefficient % Moisture Sample Rate = 21.24 Lpm Ideal Nozzle Size 9.848 mm 6/16 in Actual Nozzle Size Used 3/8 in Taken from stack sampler Humidity inside stack during operation When numbers are entered into calculator, ideal nozzle size will be displayed. Enter number here If ideal nozzle size is not available, locate nearest number. Enter what nozzle size was used for testing 14 of 18 © ' , 1. • Taken from stack sampler Humidity inside stack during operation When numbers are entered into calculator, ideal nozzle size will be displayed. Enter number here If ideal nozzle size is not available, locate nearest number. Enter what nozzle size was used for testing 14 of 18 Project No. 4786078270 File: SV29641 Appliance Innovation Model: M1718 Start Time: 7:50 Product Tested: chicken, potatoes, flatbread, sweet Cook Time::00, flat bread 1:30, veggies 3:00 End Time: 4:55 Barometric Pressure: 739.14 mmHg Recovery Time: N/A Test Date: 2013/12/18 Hood Length: 72 in Room Ambient: 23 C Dat( Time #1- Beginnini #1- En< #2- Beginnini #2- Enc IMPINGER WEIGHT Im in er Start Volume/Weight Empty Weight lbs With Content Ibs) End of Test Ibs 1 100m l- 1.312 1.532 1.340 2 100ml- 1.280 1.500 1.568 3 100 m l- 1.316 1.534 1.600 4 200g 1.334 1.776 1.910 FILTER WEIGHT 2 d S R 7 2013/12/12 2013/12/16 2013/12/16 2013/12/19 2013/12/23 2013/12/23 Gas Meter Reading im3i 7:30am 7:15am 1:15 m 3:45pm 2:00pm 6:50am 8:54am Final Weight 0.6048 0,5945 0.5984 0.5958 Filter Temp °C Exit Temp °C Gas Meter Temp °C Initial 0.6108 0.5975 0.6019 0.6018 0.6018 3.0 0.6095 0.6078 0.6075 0.6075 Timed Meter Readinas Traverse Point Number Sampling Time Gas Meter Reading im3i Or Orifice Pressure Differential AH Velocity Head AP Pump Vaccum in- Hg Stack Temp °C Probe Temp °C Filter Temp °C Exit Temp °C Gas Meter Temp °C Initial - 571.332 41 3.0 2.9 26 121 121 7 22 1 10 571.468 40 3.0 2.9 27 121 121 9 23 1 20 571.666 40 3.0 2.8 28 121 121 11 24 1 1 30 571.8681 40 3.0 2.81 27 1201 121 131 26 1 40 572.069 40 3.1 2.8 28 121 121 14 27 1 50 572.272 40 3.1 2.9 28 121 121 15 28 1 60 572.474 40 3.1 2.9 28 121 121 16 29 2 10 572.680 40 3.2 2.9 26 121 121 13 30 2 20 572.883 40 3.3 2.9 26 121 121 13 30 2 30 573.089 41 3.2 2.9 26 121 121 13 31 2 40 573.295 40 3.2 2.9 26 121 121 14 31 2 50 573.502 40 3.3 2.91 26 1201 121 151 31 2 60 573.7081 41 3.3 2.9 26 121 121 161 31 3 10 573.915 41 3.0 2.9 29 121 121 13 31 3 20 574.122 41 2.8 2.9 27 121 121 13 31 3 30 574.329 41 2.8 2.9 28 121 120 13 31 3 40 574.536 41 2.7 2.9 27 121 121 14 31 3 50 574.742 41 2.8 2.9 27 121 121 16 31 3 60 574.950 42 2.91 2.9 27 121 121 12 31 4 10 575.159 41 3.2 2.9 281 121 1211 12 31 4 1 20 575.3661 41 3.1 2.9 27 121 121 121 31 4 30 575.576 41 3.2 2.9 29 121 121 13 31 4 40 575.780 41 3.0 2.9 28 121 121 14 31 4 50 575.988 41 3.1 2.9 28 121 121 12 31 4 60 576.197 41 3.1 2.9 28 121 121 11 31 5 10 576.406 41 3.2 2.9 28 121 121 11 31 5 20 576.614 40 3.0 2.9 27 1211 121 12 31 5 30 576.822 40 3.2 2.9 28 121 121 13 31 5 1 40 577.030 40 3.1 2.9 27 120 121 14 31 5 50 577.238 41 3.2 3.0 28 121 121 14 32 5 60 577.448 41 3.1 3.0 28 121 121 15 32 6 10 577.660 42 2.2 2.9 27 121 121 10 32 6 20 577.873 42 2.0 2.9 27 121 121 10 32 6 30 578.085 42 2.2 2.9 271 121 121 10 32 6 40 578.298 42 2.11 3.0 27 121 121 11 32 6 50 578.510 41 2.1 3.0 27 121 121 12 32 6 60 578.722 42 2.1 3.0 27 121 121 12 32 7 10 578.934 42 1.7 3.0 25 121 121 13 32 7 20 579.146 42 1.8 3.0 26 121 120 13 32 7 30 579.357 41 1.9 3.0 25 121 121 14 32 7 40 579.570 42 2.0 2.91 25 121 121 9 32 7 50 579.785 42 2.0 2.9 251 121 121 9 32 7 60 579.999 42 2.0 2.9 25 121 121 9 32 8 10 580.213 42 2.8 2.9 27 121 121 10 32 8 20 580.426 42 2.8 2.9 28 121 121 11 32 8 30 580.639 42 2.8 2.9 27 121 121 11 32 8 40 580.851 42 2.8 2.9 28 121 121 12 32 8 50 581.064 42 2.81 2.9 27 121 121 12 32 8 60 581.276 42 2.8 2.9 27 121 121 13 32 8 70 8 80 8 90 8 100 8 110 8 120 Average Gas Meter Outlet Temperature: 30.592 °C Average Gas Meter Outlet Temperature: 87.065306 °F AH = 41.0816 mm H2O Tm = 547.07 R A H = 1.6173871 in H2O 15 of 18 Project No. 4786078270 File: SV29641 Appliance Innovation Model M1718 Start Volume of Sample Bottles Initial Weight of Dishes And Drying Process Sample Sample Bottle Start Volume ml Bottle Start Volume ml 1 2 34.0 5 215.0 3 29.0 6 435.0 4 430.0 7 165.0 Initial Weight of Dishes And Drying Process Initial Weight of Bottle 2 And Drying Process Solid Phase Drying Process (g) Enter Dish # Final Weight of Dish 1 1 2 3 4 5 Final Weight After Drying Dish 2 1.0370 1.0372 1 1.0373 1.0373 1.0373 Dish Dish Initial Weight of Bottle 3 And Drying Process Solid Phase Drying Process (g) Enter Dish # Final Weight of Dish 1 2 3 4 5 Final Weight After Drying Dish 3 1.0051 1.0109 1.0109 1.0109 1.`0149 Dish Dish Initial Weight of Bottles 4 & 5 And Drying Process (Solvent Phase) Solid Phase Drying Process (g) Enter Dish # Final Weight of Dish 1 1 2 3 4 1 5 Final Weight After Drying Dish 5 1.0853 1.0870 1.0870 1.0870 1.0870 Dish Dish 16 of 18 Initial Weight (g) 1 2 Drying Process (g) 3 4 5 6 Final Weight of Dish Dish 1 Dish 2 1.0369 1.0371 1.0370 1.0370 1.0370 Dish 3 1.0050 1.0050 1.0051 1.0051 1.0051 Dish 4 1.0771 1.0773 1.0775 1.0773 1.0773 1 0773 Dish 5 1.0851 1.0853 1.0853 1.0853 Dish 6 1.1027 1.1028 1.1028 1.1028 1.1028 Dish 7 1.0806 1.0807 1.0806 1 1.0806 Dish 8 Dish 9 Dish 10 Initial Weight of Bottle 2 And Drying Process Solid Phase Drying Process (g) Enter Dish # Final Weight of Dish 1 1 2 3 4 5 Final Weight After Drying Dish 2 1.0370 1.0372 1 1.0373 1.0373 1.0373 Dish Dish Initial Weight of Bottle 3 And Drying Process Solid Phase Drying Process (g) Enter Dish # Final Weight of Dish 1 2 3 4 5 Final Weight After Drying Dish 3 1.0051 1.0109 1.0109 1.0109 1.`0149 Dish Dish Initial Weight of Bottles 4 & 5 And Drying Process (Solvent Phase) Solid Phase Drying Process (g) Enter Dish # Final Weight of Dish 1 1 2 3 4 1 5 Final Weight After Drying Dish 5 1.0853 1.0870 1.0870 1.0870 1.0870 Dish Dish 16 of 18 Initial Weight of Bottles 4 & 5 And Drying Process (Water Phase) Solid Phase Drying Process (g) Enter Dish # Final Weight of Dish 1 2 3 4 5 Final Weight After Drying Dish 7 1.0806 1.0828 1.0829 1.0829 1.0829 Dish Dish Initial Weight of Bottles 6 & 7 And Drying Process (Solvent Phase) Solid Phase Drying Process (g) Enter Dish # Final Weight of Dish 1 2 3 4 5 Final Wei ht After Drying Dish 4 1.0773 1.0778 1.0778 1.0777 1.0777 1.0777 Dish Dish Initial Weight of Bottles 6 & 7 And Drying Process (Water Phase) Solid Phase Drying Process (g) Enter Dish # Final Weight of Dish 1 2 3 4 5 Final Weight After Drying Dish 6 1.1028 1.1032 1.1033 1.1033 1.1033 Dish Dish Final Weight of All Bottles Sample Bottle 2 Sample Bottle 3 Sample Bottle 4&5Solvent Ph. 0.3 milligrams 5.8 milligrams 1.7 milligrams Sample Bottle 4&5 Water Ph. Sample Bottle 6&7 Solvent Ph. Sample Bottle 6&7 1 Water Ph. 2.3 milligrams 0.4 milligrams 0.5 milli rams 17 of 18 Project No. 4786078270 File: SV29641 Appliance Innovation Model: M1718 Start Time: 7:50 Cook Time: lein frozen 3:00, flat bre Recovery Time: N/A End Time: 4:55 Test Date: 2013/12/18 Product Tested: chicken, potatoes, flatbread, sweet fries Barometric Pressure: 739.14 Post -Test Data Gas Meter ReadingGas Meter Reading initial 571.332 m3 End 581.276 m3 Vm Y- Constant Tstd constant Tm Barometric Pressure 9.944 m3 351.166 ft' 0.909 528.0 R 547.1 R 739.14 mmHg 29.1 inHg Pstd 30.42 inHg A H 1.617387 in H2O Vmstd 295.921 ft3 8.379545 m3 Number from most recent LEM calibration certificate NBK43745 Post -Filter Data Filter paper 607.5 mg Weight at End of Test Filter AR 601.8 mg Weight at Begining of Test delta H 5.7 mg Change of Weight at End of Test Post -Acid Used Acetone (Blank) 0.3 mg Bottle 2 Mc 8.6 mg Acetone (Wash) 5.8 mg Bottle 3 Solvent Phase (Wash) 1.7 mg Bottles 4&5 Mn 14.3 mg Water Phase (Wash) 2.3 mg Bottles 4&5 Solvent Phase (Blank) 0.4 mg Bottles 6&7 Water Phase (Blank) 0.5 mg Bottles 6&7 Total Grease Emissions Cs=Mn/Vmstd Reported Grease Emission mg/m3 I b/h r/ft 18 of 18 �g4.t9S1, �UPERTIIKO TEMPORARY CERTIFICATE OF OCCUPANCY FORM COMMUNITY DEVELOPMENT DEPARTMENT . BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL Alb5 6 Ir 10300 TORRE AVENUE CUPERTINO, CA 95014-3255 3 (408) 777-3228 - FAX (408) 777-3333 buiiding(&cuoertino.org APN ` j I y TYPE OF CONSTR SP #: fi c1 e OCC LOAD DA # r� PROJECT VALUATION: SITE ADDRESS; 1 5-rGUSC,O S CtZ�-_LP_ _iE OL . ❑ APPROVED OWNER'S NAME: f�"E EGqE,,j Date: .... �PHONE#: FAX #: Other: Signature:... . MAI LING ADDRESS (if different from site address): CI APPROVED APPROVED WITH CONDITIONS D0 n1 CONTRACTOR: A PZV_W a 5,FV6FO #E #: CONTACT. ,� � PHONE M FAX #: p TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION✓ CODE '�jS b (BLD80NDSJ ❑ CHECK ❑ CASH BOND OF BOND: 5Km1n-10Kmax d EDITION: TCO EXPIRATION DATE X ' RATION MAX}: FEE: $286.OQ/mo TOTAL FEE: $ 063-6,0--a- [1TE'MPOCCI USE TYPE OF CONSTR FLOOR AREA OCC LOAD LEVEL COMMENT ❑ APPROVED APPROVED WITH CONDITIONS* u Iic rks ❑ APPROVED APPROVED WITH CONDITIONS" Signature' .. Date: .... Other: Signature:... . A;?p CI APPROVED APPROVED WITH CONDITIONS D0 n1 OTHER DEPARTMENT I AGENCY APPROVALS: Planning Signature:.., ..... Date ❑ APPROVED ❑ APPROVED WITH CONDITIONS` Fire r Signature:.. . j Date: (' ❑ APPROVED APPROVED WITH CONDITIONS* u Iic rks ❑ APPROVED APPROVED WITH CONDITIONS" Signature' .. Date: .... Other: Signature:... . Dater" g CI APPROVED APPROVED WITH CONDITIONS D0 n1 *CONDITIONS OF COMPLETION Attach a letter signed by the contractor and owner of the property stating the list of items required to be completed for each individual Department Before final occupancy can be granted. Include approximate completion dates for each item. The undersigned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or buildings complete and in compliance with all building codes., ordinances and regulations and ready for inspection prior to the expiration date specified. If this Temporary Certificate of Occupancy expires, the total amount nd may be forfeited and the non-compliance may result in farce ent action. - Owner Cont ct Signature:r2CA Date; .rte. . ,.. Si nature .......................... ........ Date; . This temporary certificate ensures that all fire protection and life safety systems have been completed, 7praved for the specific area of the building specified above to provide a reasonable degree of safety nilar emergencies. from tested iuilding Official .Print:........... ........................ ate:.........................:.. DEPARTMENT ACTION: After determination, copies to: 1) applicant, 2permit file t r,,,,pOccFornz 2013.4 • 5, 17114 r a PERMIT FEE RECEIPT Case # 15020045 cutse�c-r,�,ra Date Printed: 02125)2016 CITY OF CUPERTINO - FEES RECEIPT Case Number: 15020045 Permit No. 15020045 Project Valuation: 835000.00 Date Submitted: 02/0912015 Permit Type: 1A TI Address/APN: 19399 STEVENS CREEK 13LVD (316 20 112) Receipt #: 201734 Scope of Work: LYFE KITCHEN,COMM.T.I ON(E)SHELL BUILDING 4,092 SQ FT REV # 1 - ROOF TOP EQUIPMENT DETAILS, ADD OUTLET & KITCHEN EQUIPMENT CHANGES - ISSUED 2/23/2016 Contact Type:: Applicant Full Name: MAIN STREET CUPERTINO AGGREGATOR Primary Phone: (916) 503-1073 Address: 2882 SAND HILL RD STE 241 MENLO PARK, C. Email: mrohde0vallcoshopninamall.corn 021251206-3:00:4413M - Generated by: paulos 11X T. lnfoYitSsttcsn= Building - Bond TCO GOOD TILL 3/2512016 AmoinE. $8,350.00 Temporary Occupancy TCO GOOD TILL 3/25/2016 $286.00 _..:. ` „.-.:,•_::: —� mow: OLS t :_ =__Paytrte�i Credit Card $8,350.00 Occupancy 0212 5/2 0 1 6 DR NICHOLS Credit Card $286.00 FEE TOTAL AMOUNT PAID BALANCE DUE $8,636.00 $8,636.00 I$0,00 021251206-3:00:4413M - Generated by: paulos 11X