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15070170CITY OF CUPERTINO BUILDING PERMIT BUILDING.ADDRESS:' 39369 STEVENS CREEK BLVD CONTRACTOR: TERRA NOVA PERMIT NO: 15070170 INDUSTRIES OWNER'S NAME;` MAIN STREET CUPERTINO AGGREGATOR 1607 TICE VALLEY BLVD DATE ISSUED: 11/25/2015 OWNER'S PHONE: 6503441500 WALNUT CREEK, CA 94595 PHONE NO: (925)934-6133 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL Q COMMERCIAL EUREKA - STE 130 (SHOP 3 MAIN STREET) - T.I. TO License Class Lic BUILD OUT SHELL FOR (N) RESTAURANT (3,707 S.F.) ContractoA901A .. LIJ Date' (( 25 <5 I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section'7000) of Division 3 of the Business & Professions . Code and `that my license s;in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have andrwill maintain a certificate of consent to self -insure for Worker's Compensation as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $420000 I have and will maintain Worker's Compensation Insurance, as provided for by for the performance of the work for which this Section 3700 of the Labor Code, f APN Number: 31620109.19369 Occupancy Type: permit is issued ;> . APPLICANT CERTIFICATION I certify that 1, have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building, construction, and hereby authorize representatives of this city to enter 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by: � �/� Date: granting of this ertnit. "Additionall the applicant understands and will comply g g. p. Y> PP� with all non -point source regulations per the Cupertino Municipal, Code, Section 9.18 F RE -ROOFS: fr Date j� / All roofs shall be inspected prior to any roofing material being installed. If a roof is Signature installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ' ' ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER i, as owner of the'property, ormyemployees with wages as their sole compensation, will do the work„ and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct theprotect (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 declarationsi �� ��,i I have and,"wtll 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 District I with the Cupertino Municipal Code, Chapter 9.12 and performance of the work forwhich this permit is issued. ll ' ompensation Insurance, as provided for by will maintain compliance the Health & Safety Code, Sections 25505,255M, , and 25534. 1 haveSectionnd w the Labor or de for the performance of the work for which this Owner or authorized agent: Date: permit is;issued,;:,� in the of the work for which this permit is issued, I shall I certify,that performance not employ -any person in any, manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of'Califotnia.. If, after making this certificate of exemption, I Worker's Compensation provisions of the Labor Code, I must ' I hereby affirm that there is a construction lending agency for the performance of become subject to, the forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C,) ame Lender's Nam- APPLICANT CERTIFICATION APP Lender's Address I certify that I have read this application and state that the above information is correct. I agree,to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize' representatives of this city to enter upon'the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, and 'expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. costs' 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 Signature ;; Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 building flouUertino.org J -O'701 ❑ NEW CONSTRUCTION ❑ ADDITION ,R ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT 4 PROJECT ADDRESS p, �� I 'd ? 1 b4 APN R d.. PHONEP /(�E-M!� OWNER NAME 11)9�qq} (�l J e ib -I STREET ADDRESS y L 1 �� ®^ CITY, STATE, ZIP HCV40 1 - C 4 l a _�I�FAX lr °° 'r PHONE L 6 j p(3 E -h All CONTACT 1�TAME�Vv``J lei I!` Va p l /6° i G' �� 4 .� �`ett �Y6m � �z� tal`iva^ STREET ADDRESS Gd C %,] CITY, STATE, ZIP JSLIf 7g I / FAX916 OWNER ❑. OWNER.BUILDER AOAINTERAGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER, ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME T_() D LICENSE NUMBER LICENSE TYPE BUS. LIC COI MANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEFR NAME NSE NUMBER BUS. LIC # COMPANY NAME N E-MAIL FAX STREET ADDRESS s V' , � $*,SOD CITY, STATE, ZIP �X Q o�e f IY PHONE A fl AS 73-1 ® i Q Im < WORK tt-- jj��a tyB v� EXISTING USE PROPOSED USE - CONSTR TYPE I 4 STORIES USE TYPE I OCC. SQ.FT. VALUATION (S) EXISTG AREA AREA NEW FLOOR AREA. DEMO AREA TOTAL NET AREA 1-3,70 BATHROOM �A REMODEL AREA �r� KTTCHE23 - 1 REMODEL AREA AM OTHER REMODEL AREA PORCHAPEADECK mA,/ A �4" TOTAL DEC ' O CH AREA GARAGE AREA: DETACH , p /,d❑ATTACH � DA'ELLING UNITS: IS A SECOND UNIT ❑ I'BS SECOND S�TIAORRYVT ❑YES - - ,0 BEING ADDED? SIO ADDITION? �N'O °`"`11 PRE -APPLICATION &,TS IF YES, PROVIDE COPY OF I IS THE BLDG AN C - T TAL VALUATION: EICHLERHOMfi? No PLANNINGAPPL4 ]NO PLANNBAGAPPROVALLETTER By my signature below, I certify to each of the following: I am the property owner or auted age o`the property oAmer's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state lays relating to building con ction. I aut riae-representatives of Cupertino to enter the above -identified property for inspection purposes. °y / SismatureofApplicant/Agent: Date: SUPPLEMENTAL INTFORMATION REQUIRED ❑ ovsR THIiCOUhTER BUII vzrtGriaixE� I '' New SFD or Multifamily dwelIings: Apply for demolition permit for existing building(s). Demolition permit is required rior to issuance of building. p q p permit for new building. EYP.RESS-© PLAI]'LiLTtG.PLA'NR7+<YiEW Bldgs: Provide a completed Hazardous Materials Disclosure sTDARv �uBL�CwoRl _ _Commercial form if any Hazardous Materials are being used as part ofthis project. MsFIR1 DEPTH Copy of Planning Approval Letter or Meeting with Planning prior to C�_1vFA70R �� SL�i�R�ISI'RI _ submittal of Building Permit application. F'SA`N'ITARY r F u _ BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 19369 STEVENS CREEK BLVD DATE: 07/23/2015 REVIEWED BY: MELISSA AP 31620 112 BP#: *VALUATION: $420,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: PENTAMATION 1A TI PERMIT TYPE: WORK EUREKA - STE 130 SHOP 3 MAIN STREET - T.I. TO BUILD OUT SHELL FOR N RESTAURANT SCOPE (3,707 S.F TYPE OF FLR AREA OCCUPANCY TYPE: CONSTR. S.f. PC FEES PC FEE ID BP FEES BP FEE ID A (Tenant Improvements) II-B,111-B,IV,V-B 1 3,707 1 $2;642.17 IATIPLNCK 1 $2,050.41 1 IATIINSP I TOTALS: I 3,707 I $2,642.17 $2,05041 I lle A Plan Check l hanb. Pleur Cheek Elec. Plan Check ;t9ech, Permit Fee: Plumb. Permit Fee: lslec. Permit /"C -e - Other 11ec h. Imp. Other Plutnb Imp. Other /s'lec. Insp. ,Zech. hap. Fee: Pha nb, hisp. Fee: Elec. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer Dist District, eta). These fees are based on the prelimina information available and are only an estimate Contact the Dept or addn'l info, FEE ITEMS (Fee Resolution 11-053 F f 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,642.17 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Reg. OT 0.0 hr's $0.00 PME Plan Check: $0.00 Permit Fee: $2,050.41 Suppl. Insp. Fee: Reg. 0 OT —0.01hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C.'onslruction .Tax: Adininistrative Fee: 0 Work Without Permit? ® Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure i TrUvel Documentation Fees: Strong Motion .Fee: 1BSEISMIC0 $117.60 Select an Administrative Item Bide Stds Commission Fee: IBCBSC $17.00 _. A T7BTTALss $4,827.18 $0.00IRTI,T_��E $4,827.18 Revised: 07/02/2015 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15070170 19369 STEVENS CREEK BLVD CUPERTINO CA 95014 OWNER'S NAME: MAIN STREET AGGREGATE DATE ISSUED: 11/25/2015 OWNER'S PHONE: PHONE NO: 925-934-6133 LICENSED CONT'RACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic. #460854 _ Contractor Date''t �E4hl N v VA J44 � aAd-s 9�E _ BLDG _ELECT _ PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECII _ 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: EUREKA - STE 130 (SHOP3 MAIN STREET) - T.L TO I hereby affirm under penalty of perjury one of the following two declarations; BUILD OUT SHELL FOR (N) RESTAURANT (3,707 S.F.) 1: 1 have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 ofthe Labor Code, for the REV#1 - CHANGES TO ARCHITECTURAL; STRUCTURAL AND performance ofthe work for which this permit is issued. MEP -ISSUED 1/25/16 z% I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 ofthe Labor Code, for the performance ofthe work for which this permit is issued. Sq. Ft Floor Area: Valuation: $420000.00 APPLICANT CERTIFICATION 1 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 comply with all non -point source regulations per the Cupertino Municipal WITHIN 180 OF PERMIT ISSUANCE OR Code, Section 9.11. 180 CALLED INSPECTION. Signature Date l/2� /,,6 Issued b _ Dates Z S' OWNER -B R DECLARATION 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 inspection. for sale {Sec.7044, Business & Professions Code) z. I, as owner of the property am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: I hereby affirm under penalty of perjury one of the following three declarations: 1. I have and will maintain a Certificate of Consent to self -insure for Worker's ALL 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 I have read the hazardous materials requirements under Chapter 6.95 of the by Section 3700 of the Labor Code, for the performance ofthe work for which California Health & Safety Code, Sections 25505, 25533, and 25534. I will this permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the B., I certify that in the performance ofthe 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 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions ofthe the Health & Safety Code, Sections 255 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or author zed agent ,, APPLICANT CERTIFICATION Date.> / % I certify that I have read this application and state that the above information is /°�'d6 CONSTRU ION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affir 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 ARCHITECT'S DECLARATION Cupertino Municipal Code, Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CONSTRUCTION PERMIT APPLICATION ' R.4 CONi10UN1 I Y DEVELOPMENT DEPART MIEN 1 • BUILDING DIVISION 10300 i ORRE AVENUE • CUPERTINO, CA 55014-3255 r (408) 777-3228 • FAX (408) 777-3333 • buiidino(a.CuDeriino.ora CUPER'fINO, ❑ NEW CONSTRUCTION ❑ ADDITION . ❑ A.L1ERATI0N! TI REb75I0N / DEFERRBD OP.IGI?�?aT PE s m PROitCf ADDRESS � V'4I L �° "°'d\ � y� 1 °3N � � � • �Lo OtiNERNAb ME 9 d`, ` j / ( I PHONZ I E-1✓aIL V�9I�v°�1 �®f��/[ g STRnETADDRESS `I W6) 5jt1 l f �� I C7 Y, STATE, ZIP 1� (� yi �i ,Q I FAX P V (l. T ✓/ /� �sg��Q� �%PQ CONTACT NAVE '� D /-f-OA J \� l _. I PHONE / 16N:.STT (7(. i J jam•' G STRE_tADDR=SS /®���� �¢ CITY,STA-, ZIP ail c yrd I F ❑ ow.,,.R D, our-R-sv D T RE3A n -1-R. AcE.-r E]CC�.�aCT OR ElCO ,-rFUCTOR M, r ElARCT-7 CT [3ElIacL *-R ❑ D�•_ioP� CON ACrOR NA.� -fp crA /�f (7 I LICENSPNU'SER I LiCTSE T YPB ( BUS. LIC coin NY NIUS STREET ADDRESS MY, STATE, ZIP I PI-ola SRC�SECTr?iG=ERNA]✓.E ACf I LICENSEh"TUINSER I BUS. LIC n 1 C0111.1.aNY NAI'm N� i S �(iV i `71 j t_IJp_L J_ FAX STP.EET ADDKFSS y ; p e % 4 I CITY, STA t. ZIP / �� �n ! rNr 9� J �ll eT t✓ L L t�c�✓ I PHOI�IE DESCRIPTION OF WORK 6ioN ®—Co ` r ` USE I PROPOSED USE CONSITI TY -t 3 I I I r i I L'SE I TYPE I OCC. I SQ.FT. I VALUATION (S) I =1 TO NEW FLOOR AREA I AP—1A REMODELAREA I REMODEL.SREh DEMOI TOTAL A-RZA l -=t AREA RE1,40DEL ARIA * DWELLING i.P.QTS:I IS A S£COND UNIT L YES ( SECOND STORY ❑ YZS I I I- FI-IrBS BEING ADDED? 0NO AITIDDON?[]-No IF l'S, PROYIDc COPY OF IS T riE BLDG Ah' ❑ 2 a FjZ tT)`3] PLA NINIGkPPLR FINO�PLATWa�GAPPROVAL L-=? I EICHLERHOME? L]NO By my signature beloN,,, I certify to each of the Collo wing: I am the property or„ner or authorized agent to actor the property o"I Der's rt�applicetion and the -information I=have.pro, ided is-cor ectivhave read=the Description of=t�%ork ander en>> it is acct*a:e I zee to c� ordinances and state lay -es Iela Tag to buildino nstr uct on I at�orize rtp-'esentatilvts'of Cupertino to enter the abosve-Inez i led pgp S gnafirs o;,Analicunt/rgent:.-M_ SI)PPLE? ANT_ _ r3;OR2l�A! ION REQUIRED New SFD or 1\Zultifa_ lily dvv--jlinES: Apply for denoli`ion De -reit for 04 £R TCOL�TFE2 exlsting buildinQ(S). D=jolition per -nit IS required prior t0 I=SllBnce Of building per -mit for new building. Cornnnierclal Bides: Provide a completed HazzardCus h�, 3terials Disclosure form it any Hazardous h4aterizis _re being used as part of This project. ug.1 1 Z�RGE f _ Copy of Plaruning Approval Letter or' -Meeting with Planning prior to �saTOR f 1: Sub -Mittal of Building Pe=t application. A V beh?W I hole read this mply,;rtli alt" P211cable lo��l�"�`= for inspection purposes. Bich Aa.p_20II. doc revised 06/21/13 CITY OF CUPERTINO FEE ESTIMATOR — RTTILDING DIVIRION ADDRESS: 19369 Stevens Creek Blvd DATE: 11/25/2015 REVIEWED BY: Phuong APN: 316 20 112 BP#: 15070170 *VALUATION: 1$8,000 *PERMIT TYPE: Building Permit PLAN CHECKTYPE: Tenant Improvement PRIMARY Commercial Building USE: $0.00 PENTAMATION 1GENCOM PERMIT TYPE: WORK Rev#1 - Revision throughout SCOPE $0.00 :ticch. Plan I_ '&'cl, 14'ech' PerQrni . ew: K,vmb. Check Other _ '; trr j; z�Iec, Ph,-,. (,lte .k Oilier l.Fc L`. hw4 . fe,,.* i s 3 tee,` � Iaizrrrll. e: Ir-sp. NOTE., This estimate does not includefees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary, Sewer District, School District, etc.). Thesefees are based on the preliminary, information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E ': 7/U13I FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes (j) No $0.00 4 hours Plan Check, Hourly $572.00 ISTPLNCK Suppl. PC Fee: F Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0..00 Permit Fee: $0.00 Suppl. Insp. Fee I& Reg. 0 OT F0, 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ..4drk LbfbWrY-ifive 's?v - - 0 Work Without Permit? 0 Yes No $0.00 Advanced`Planning Fee: $0.00 Select a Non -Residential Building or Structure 1'Pavel Documentr ion 1<ecrs: Strong Motion Fee: IBSEISMICO $2.24 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 m $3.4 $5.00L T' ...__. $575.24 Revised: 10/01/2015 1 TTrt R N N 0 U S WM T R I E S General Contracting • Construction Management • Development and Design November 23, 2015 City of Cupertino Building Inspection Division Re: Permit Authorization 19369 Stevens Creek Blvd., Ste. 130 Cupertino, CA 95014 To Whom It May Concern: This letter is to inform you that Levi Henderson is authorized to sign for any and all permits or applicable documentation with regard to Eureka! Burger located at 19369 Stevens Creek Blvd., Ste. 130 Cupertino, California 95014. If you require anything further, please do not hesitate to contact our office. Sincerely, Ronald L. Taylor President RLT/eb/Permit/2604 1607 Tice Valley Boulevard ■ Walnut Creek, CA 94595 ■ (925) 934-6133 ■ FAX: (925) 934-6676 www.terranova-ind.com 1= - STATEMENT OF SPECIAL INSPECTIONS, 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT ` BUILDING DIVISION xLeswTSALVADOR, P.s..C8.O.'BUILDING OFFICIAL CupERTIm�� 1oo0oT0RnsAVENUE ^CUPsRT|NO.CA9aO14'3255 | (408)r7r'uozO'FAX (4O8)r77'33z3^ SITE 19369 STEVENS CREEK BLVD, SUITE 130 -ME in P# ADDRESS RAI Al I Ylur-:2 Q1 loll 310331 8237 PROJECT DESCRIPTION* EUREKA! - T.I. TO BUILD OUT SHELL AT MAIN STRE& B IVI I i I AL- This'STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 17 This form Is structured after and used by permission frorn the StrucKiral Engineer Association of Northern California's (SEAONtM�a statement of Special Inspections. Also, InGluded with this form is the following: F "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 - 6). 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 plans and specifications shall also be performed, Sp ecial Inspections inyp*rtiomoand Testing w@|beperfonmodineocordunomwith the approved plans and specifications, this statement and CBC Sections 1704.i7O5. 17O0.17O7.and 17O8Interim reports will b:submitted |othe Building {Nf�m and the Ro8���dDes�n ����U��|� Pm�s�ono|inRaupoou�|nCharge inanm�once _ '"�=�"n�^, aFinal Report ofSpecial Inspections documenting required Special inxpe �omepondoxno�dNV �� ���� txoi000echonunxu||b*»uhmixodpiorm|oouun000faCr�i8;moorUuonnd 7O4.12).The Fin�Repp�will - ~ ��«� document: - , Roqu|mdvp*dr|invnom|nno, -m��( 4musAF0pC, ' ° Correction nydiscrepancies noted ininspections. The Owner recognizes his her obligation to ensure that� Prepared By: Project W Engineer 0 Architect Owner Name: L3 Ir. This'STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 17 This form Is structured after and used by permission frorn the StrucKiral Engineer Association of Northern California's (SEAONtM�a statement of Special Inspections. Also, InGluded with this form is the following: F "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 - 6). 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 plans and specifications shall also be performed, Sp ecial Inspections inyp*rtiomoand Testing w@|beperfonmodineocordunomwith the approved plans and specifications, this statement and CBC Sections 1704.i7O5. 17O0.17O7.and 17O8Interim reports will b:submitted |othe Building {Nf�m and the Ro8���dDes�n ����U��|� Pm�s�ono|inRaupoou�|nCharge inanm�once _ '"�=�"n�^, aFinal Report ofSpecial Inspections documenting required Special inxpe �omepondoxno�dNV �� ���� txoi000echonunxu||b*»uhmixodpiorm|oouun000faCr�i8;moorUuonnd 7O4.12).The Fin�Repp�will - ~ ��«� document: - , Roqu|mdvp*dr|invnom|nno, -m��( 4musAF0pC, ' ° Correction nydiscrepancies noted ininspections. The Owner recognizes his her obligation to ensure that� Prepared By: Project W Engineer 0 Architect Owner Name: L3 Ir. Inspection Agency I Inspector Name: ........... .. Building Official or designee: 001 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 on 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 testing and special inspection agencies that will be retained to conduct tests and inspection on this project: EXPERTISE FIRM i INSPECTOR INFORMATION * 1. Special Inspection (except for Firm..Korbinac er..Engineer. ng............Addr......490.h-.eston.CL.Suite..B................................ geotechnical) city ... Livennoae................................................................................ state .CA ............... zip ....9.455.1..... Telephone..925.45.4..9.033....... Fax ............................................ Email.,bruna@korhmad-terinc..co 2. Material Testing Firm. ............... ... .... Addr......yy.�.-.y .................. Swr+ 1.... �.... / CitYl, ............................................................................... r�L State ...Vim.......Ziip {��.Z. ... /n�� Telephoneg2S-W. 77 TZ...Fax12t01•(032�........Email.�.�1. .�{w�`. 3. Geotechnical Inspections Firm ......................... .............. .............................. Addr.................................. ....................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax............................................ Email......................................................... 4. Other. Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ........... I.......... 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 Section 1705.3: INDIVIDUAL COMPONENTS DESIGNED TO RESIST SEISMIC DESIGN FORCES (ASCE 7-10 SECTION 13.3) AT NEW MECHANICAL UNITS. SEE CONSTRUCTION DRAWINGS. The extent of the seismic -force -resisting system is defined in more detail in the construction documents. WIND REQUIREMENTS (Section 1705.4.1 Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: NOT APPLICABLE PER CBC 1704.5.2. The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForna_2012.doe revised 09106/12 Cull SCHEDULE OF SPECIAL INSPECTION SITE ADDRESS 19369 STEVENS CREEK BLVD, SUITE 130 APN BP# PROJECT DESCRIPTION: EUREKA! - T.I. TO BUILD OUT SHELL AT MAIN STREET Notation Used in Table: Column headers: C Indicates continuous inspection is required. P Indicates periodic inspections are required. The notes and/or contract documents should clarify. Box entries: X Is placed in the appropriate column to denote either "C" continuous or "P" periodic inspections. --- Denotes an activity that is either a one-time activity or one whose frequency is defined in some other manner. Additional detail regarding inspections and tests are provided in the project specifications or notes on the drawings. VERIFICATION AND INSPECTION C P REFERENCED IBC REFERENCE STANDARD INSPECTION OF FABRICATORS 1. ❑ Inspect fabricator's fabrication and quality control _ 1704.3 procedures. INSPECTION OF STEEL 1. Material verification of high-strength bolts, nuts and washers. e Identification marking to conform to ASTM stds AISC 360, specified in the approved construction documents. --- X Section A3.3 and applicable ASTM material standards ❑ Inspect fabricator's fabrication and quality control procedures. - X 2. Inspection of high-strength bolting: ^ �I Snug -tight joints. --- X ❑ Pretensioned and slip -critical joints using turn -of -nut with matchmarking, twist -off bolt or direct tension --- X AISC 360, indicator methods of installation. Section M2.5 1704.3.3 ❑ Pretensioned and slip -critical joints using turn -of -nut without matchmarking or calibrated wrench methods X --- of installation. 3. Material verification of structural steel and cold -formed steel deck. ^ )� For structural steel, identification markings to conform X AISC 360, to AISC 360. Section M2.5 For other steel, identification markings to conform to ASTM standards specified in the approved --- X Applicable ASTM construction documents. material standards ❑ Manufacturer's certified test reports. ___ X SpeciainspeclionForm 2012.doc revised 09106/12 VERIFICATION AND INSPECTION C p REFERENCED STANDARD IBC IREFERENCE 4. Material verification of weld filler materials: Identification marking to conform to AWS specification in the approved construction documents. _ X AISC 360, Section A3.5 and applicable AWS A5 documents 1704.3 ❑ Manufacturer's certificate of compliance required. --- X --- --- 5. Inspection of welding: a. Structural steel and cold -formed steel deck: ❑ Complete and partial joint penetration groove welds. X --- AWS D1.1 1704.3.1 ❑ Multipass fillet welds. X -- ❑ Single -pass fillet welds > 5116" X --- ❑ Plug and slot welds. X --- Single -pass fillet welds <= 5/16" --- X Floor and roof deck welds. --- X AWS D1.3 b. Reinforcing steel: ❑ Verification of weldability of reinforcing steel other than ASTM A 706. X AWS D1.4 ACI 318: Section 3.5.2 ❑ Reinforcing steel resisting flexural and axial forces in intermediate and special moment frames, and boundary elements of special structural walls of concrete and shear reinforcement. X --- ❑ Shear reinforcement. X --- ❑ Other reinforcing steel. --- X 6. Inspection of steel frame joints details for compliance: ❑ Details such as bracing and stiffening. --- X --- 1704.3.2 ` 00 Member locations. --- X it Application of joint details at each connection. --- X VERIFICATION AND INSPECTIONC p REFERENCED STANDARD IBC IREFERENCE INSPECTION OF WELDING 1. ❑ Welded studs when used for structural diaphragms. -- X --- 1704.3 2. ❑ Welding of cold -formed steel framing members. --- X 3. ❑ Welding of stairs and railing systems. --- X SpeciahispecionForm_2012.doe revised 09/06/11 VERIFICATION AND INSPECTION C p REFERENCED IBC STANDARD IREFERENCE INSPECTION OF CONCRETE 1. ❑ Inspection of reinforcing steel, including prestressing --- X ACI 318: 3.5, 7.1-7.7 1913.4 tendons and placement. 2. ❑ Inspection of reinforcing steel welding in accordance AWS D1.4 ACI 318: with Table 1704.3 Item 5b. _ 3.5.2 3. ❑ Inspection of bolts to be installed in concrete prior to and during placement of concrete where allowable X ACI 318: 8.1.3, 1911.5, 1912.1 loads have been increased or where strength design 21.2.8 is used. •4. Of Inspection of anchors installed in hardened concrete. --- X ACI 318: 1912.1 5. ❑ Verifying use of required design mix. 1904.2.2,1913.2, --- X ACI 318: 1913.3 6. ❑ At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength tests, perform slump and air X --- ASTM C 31 1913.10 content tests and determine the temperature of the concrete. ACI 318: 5.6, 5.8 7. ❑ Inspection of concrete and shotcrete placement for X --- ACI 318: 5.9, 5.10 1913.6, 1913.7, proper application techniques. 1913.8 8. ❑ Inspection for maintenance of specified curing --- X ACI 318: 5.11-5.13 1913.9 temperature and techniques. 9. Inspection of prestressed concrete: ❑ Application of prestressing forces. X --- ACI 318: 18.20 ❑ Grouting of bonded prestressing tendons in the X --- ACI 318: 18.18.4 seismic force -resisting system. 10. ❑ Erection of precast concrete members. --- X ACI 318: Ch. 16 --- 11. ❑ Verification of in-situ concrete strength, prior to stressing of tendons in posttensioned concrete and --- X ACI 318: 6.2 --- prior to removal of shores and forms from beams and structural slabs. 12. ❑ Inspect formwork for shape, location, and dimensions X ACI 318: 6.6.1 of the concrete member being formed. --- --- 13. ❑ Bolts Installed in Existing Masonry or Concrete ❑ Direct tension testing of existing anchors. --- X See ICC ES Reports form special inspection requirements for proprietary products ❑ Direct tension testing of new bolts. --- X ❑ Torque testing of new bolts. --- X ❑ Prequalification test for bolts and other types of X anchors. 14. ❑ Other: SpeciahispectionForm-2 012. doc revised 09106112 SpeeiainspeelionForn?_ 2012.doc revised 09106:'12 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 INSPECTION OF LEVEL 1 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved --- X --- --- Art. 1.5 submittals shall be verified. 2. ❑ Verification of f'm and f'AAC prior to construction --- X --- --- Art. 1.413 except where specifically exempted by this code. 3. ❑ Verification of slump flow and VSI as delivered to X --- --- --- Art. 1.513.1.b.3 the site for self consolidating grout. 4. As masonry construction begins, the following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar. --- X --- --- Art. 2.6A ❑ Construction of mortarjoints. --- X --- --- Art.3.313 ❑ Location of reinforcement, connectors, --- X --- --- Art. 3.4, 3.6A prestressing tendons, and anchorages. ❑ Prestressing technique. --- X --- --- Art. 3.613 ❑ Grade and size of prestressing tendons and X --- --- Art. 2.413, 2AH anchorages. 5. During construction the inspection program shall verify: ❑ Size and location of structural elements. --- X --- --- Art. 3.3F ❑ Type, size, and location of anchors, including Sec. 1.2.2(e), other details of anchorage of masonry to --- X --- 1.16.1 --- structural members, frames or other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and --- X --- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X --- --- --- ❑ Preparation, construction and protection of masonry during cold weather (temperature below - _ X Sec. 2104.3, --- Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing X --- --- --- Art. 3.66 force. 6. Prior to grouting the following shall be verified to ensure compliance: ❑ Grout space is clean. --- X --- --- Art. 3.2D ❑ Placement of reinforcement and connectors and - X --- Sec. 1.3 Art. 3.4 prestressing tendons and anchorages. ❑ Proportions of site -prepared grout and _ _ X --- --- Art. 2.613 prestressing grout for bonded tendons. ❑ Construction of mortar joints. --- X --- --- Art. 3.36 7. Grout placement: ❑ Grout placement shall be verified ensure X --- --- --- Art. 3.5 compliance. ❑ Observe grouting of prestressing bonded X --- --- --- Art 3.6C tendons. SpeeiainspeelionForn?_ 2012.doc revised 09106:'12 VERIFICATION AND INSPECTION7 C P REFERENCED STANDARD IBC IREFERENCE INSPECTION OF WOOD 1. ❑ Inspect prefabricated wood structural elements and --- assemblies in accordance with Section 1704.2. --- 1704.6 2. ❑ Inspect site built assemblies. --- --- 3. Inspect high -load diaphragms: ❑ Verify grade and thickness of sheathing. --- • Verify nominal size of framing members at adjoining - - panel edges. --- 1704.6.1 ❑ Verify nail or staple diameter and length, --- --- ❑ Verify number of fastener lines, --- --- ❑ Verify spacing between fasteners in each line and at --- --- edge margins. 4. ❑ Metal -plate -connected wood trusses spanning 60 feet or greater: Verify temporary installation restraint/bracing and the permanent individual truss --- X --- 1704.6.2 member bracing are installed in accordance with the approved truss submittal package. REQUIRED VERIFICATION AND INSPECTION OF SOIL 1. ❑ Verify materials below footings are adequate to X achieve the desired bearing capacity. 2. ❑ Verify excavations are extended to proper depth and X have reached proper material. 3. ❑ Perform classification and testing of compacted fill X materials. _ --- Table 1704.7 4. ❑ Verify use of proper materials, densities and lift thicknesses during placement and compaction of X --- compacted fill. 5. ❑ Prior to placement of compacted fill, observe subgrade --- X and verify that site has been prepared properly. REQUIRED VERIFICATION AND INSPECTION OF DEEP DRIVEN FOUNDATION ELEMENTS 1. ❑ Verify element materials, sizes and lengths comply X _-- with the requirements. 2. ❑ Determine capacities of test elements and conduct X additional load tests, as required. 3. ❑ Observe driving operations and maintain complete X --- and accurate records for each element. 4. ❑ Verify locations of piles and their plumbness, confirm type and size of hammer, record number of blows per --- Table 1704.8 foot of penetration, determine required penetrations to X --- achieve design capacity, record tip and butt elevations and document any damage to foundation element. 5. ❑ For steel elements, perform additional inspections in accordance with Section 1704.3. 6. ❑ For concrete elements and concrete filled elements, perform additional inspections in accordance with --- --- Section 1704.4. SpecialnspectionForm 2012.doc revised 09106112 SpecialnspeclionForm_2012.doe revised 09'06/12 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 5301ASCE 5 530/ASCE 6 8. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be --- X 2105.2.2, --- Art. 1.4 observed. 2105.3 INSPECTION OF LEVEL 2 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved --- X --- --- Art. 1.5 submittals. 2. ❑ Verification of fm and f'AAC prior to construction and for every 5,000 square feet during --- X --- -- Art. 1.413 construction. 3. ❑ Verification of proportions of materials in premixed or preblended mortar and grout as --- X --- --- Art. 1.513 delivered to the site. 4. ❑ Verification of slump flow and VSI as delivered to X --- --- --- Art. 1.513.1.b.3 the site for self consolidating grout. 5. The following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar, grout, and X --- --- Art. 2.6A prestressing grout for bonded tendons. ❑ Placement of masonry units and construction of --- X --- --- Art. 3.313 mortar joints. ❑ Placement of reinforcement, connectors and --- X --- Sec. 1.15 Art. 3.4, 3.6A prestressing tendons and anchorages. ❑ Grout space prior to grouting. X --- --- --- Art. 3.21) ❑ Placement of grout. X --- --- --- Art. 3.5 ❑ Placement of prestressing grout. X --- --- --- Art. 3.6C ❑ Size and location of structural elements. --- X --- --- Art. 3.3F ❑ Type, size, and location of anchors, including other details of anchorage of masonry to X --- -- Sec.1.2.2(e) --- structural members, frames and other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and --- X --- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X --- Sec. 2.1.9.7.2, --- 3.3.3.4 (b) ❑ Preparation, construction, and protection of masonry during cold weather (temperature below ___ X Sec. 2104.3, --- Art. 1.8C, 1.81D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing X --- --- --- Art. 3.613 force. 6. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be X --- 2105.2.2, --- Art. 1.4 observed. 2105.3 SpecialnspeclionForm_2012.doe revised 09'06/12 VERIFICATION AND INSPECTION C P REFERENCED IBC STANDARD REFERENCE 7. ❑ For specialty piles, perform additional inspections as determined by the registered design professional in --- --- --- Table 1704.8 responsible charge. _. _.............. ............................... ................ _..— __........._._ -- REQUIRED VERIFICATION AND INSPECTION OF CAST -IN-PLACE DEEP FOUNDATION ELEMENTS 1 ❑ Observe drilling operations and maintain complete and X - accurate records for each element. 2. ❑ Verify placement locations and plumbness, confirm element diameters, bell diameters (if applicable), lengths, embedment into bedrock (if applicable), and X --- --- Table 1704.9 adequate end -bearing strata capacity. Record concrete or grout volumes. 3 ❑ For concrete elements, perform additional inspections in accordance with Section 1704.4. HELICAL PILE FOUNDATIONS 1. ❑ Record installation equipment used, pile dimensions, tip elevations, final depth, final installation torque. 1704.10 SPRAYED FIRE-RESISTANT MATERIALS Physical and visual tests 1. Condition of substrates. ❑ Inspect surface for accordance with the approved fire - resistance design and the approved manufacturer's --- --- written instructions. ❑ Verify minimum ambient temperature before and after application. X ❑ Verify ventilation of area during and after application. --- X 2. ❑ Measure average thickness per ASTM E605 and Section 1704.12.4. --- -" --- 1704.12.1 3. ❑ Verify density of material for conformance with the approved fire-resistant design and ASTM E605. (Ref. --- --- Section 1704.12.5) 4. ❑ Test cohesive/adhesive bond strength per Section 1704.12.6. 5. ❑ Condition of finished application. MISCELLANEOUS 1. Mastic and Intumescent Fire -Resistant Coating. --- --- --- 1704.13 2. Exterior Insulation and Finish Systems (EIFS). Water - resistive barrier coating when installed over a sheathing --- --- --- 1704.14 substrate. 3. Special Cases --- --- 1704.15 4. Smoke Control System --- --- --- 1704.16 5. Seismic Resistance ❑ Suspended ceiling systems and their anchorage. --- --- --- 1705.3 [4.3] SpecialnspeclionF'orrn_2012.doc revised 09.,'06112 VERIFICATION AND INSPECTIONC p REFERENCED STANDARD IBC REFERENCE 6. Wind Resistance ❑ Roof cladding and roof framing connections. --- -- --- ❑ Wall connections to roof and floor diaphragms and framing. ❑ Roof and floor diaphragm systems, including collectors, drag struts and boundary elements. ❑ Vertical wind -force -resisting systems, including braced frames, moment frames, and shear walls. ❑ Wind -force -resisting system connections to the foundation. ❑ Fabrication and installation of systems or components required to meet the impact resistance requirements --- --- --- of Section 1609.1.2. SPECIAL INSPECTION FOR WIND REQUIREMENTS 1. Structural Wood ❑ Inspect field gluing operations of elements of the main X wind -force -resisting system. --- 1706.2 ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the main windforce-resisting _- X system, including wood shear walls, wood diaphragms, drag struts, braces and hold-downs. 2. Cold -Formed Steel Framing ❑ Welding of elements of the main wind -force -resisting X system. ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the main --- 1706.3 wind -force -resisting system including shear walls, -- X braces, diaphragms, collectors (drag struts) and hold- downs. 3. Wind -resisting components ❑ Roof cladding. — --- X --- 1706.4 ❑ Wall cladding. --- X SPECIAL INSPECTIONS FOR SEISMIC RESISTANCE 1. ❑ Special inspection for welding in accordance with the X --- 1707.2 quality assurance plan requirements of AISC 341. 2. Structural Wood ❑ Inspect field gluing operations of elements of the X seismic -force -resisting system. ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the seismic -force -resisting 1707.3 system, including wood shear walls, wood --- X diaphragms, drag struts, braces, shear panels and hold-downs. 3. Cold -Formed steel light -frame construction ❑ Welding of elements of the seismic -force -resisting X 1707.4 system. SpecialnspectiorlFnrm 2012. doe revised09/00112 Inspection of screw attachments, bolting, anchoring, and other fastening of components within the seismic- _ X force -resisting system including shear walls, braces, diaphragms, collectors (drag struts) and hold-downs. 4. Storage racks and access floors ❑ Anchorage of storage racks 8 feet or greater in height X 1707.5 and access floors. 5. Architectural components ❑ Inspect erection and fastening of exterior cladding weighing more than 5 psf and higher than 30 feet --- X above grade or walking surface. ❑ Inspect erection and fastening of veneer weighing more than 5 psf.and higher than 30 feet above grade --- X or walking surface. --- 1707.6 ❑ Inspect erection and fastening of all exterior non- bearing walls higher than 30 feet above grade or -- X walking surface. ❑ Inspect erection and fastening of all interior non- bearing walls weighing more than 15 psf and higher --- X than 30 feet above grade or walking surface. 6. Mechanical and Electrical Components ❑ Inspect anchorage of electrical equipment for X emergency or stand-by power systems. _ _ Inspect anchorage of non -emergency electrical - X equipment. ❑ Inspect installation of piping systems and associated mechanical units carrying flammable, combustible, or --- X --- 1707.7 highly toxic contents. ❑ Inspect installation of HVAC ductwork that contains —_ X hazardous materials. ❑ Inspect installation of vibration isolation systems —_ X where required by Section 1707.7. 7. ❑ Verify that the equipment label and anchorage or mounting conforms to the certificate of compliance --- --- ___ 1707.8 when mechanical and electrical equipment must be seismically qualified. 8. ❑ Seismic isolation system: Inspection of isolation --- X --- 1707.9 system per ASCE 7 — Section 17.2.4.8 9. ❑ Obtain mill certificates for reinforcing steel, verify compliance with approved construction documents, --- -- --- 1708.2 and verify steel supplied corresponds to certificate. 10. ❑ Structural Steel: Invoke the QAP Quality Assurance requirements in AISC 341. ___ _ ___ 1708.3 11. ❑ Obtain certificate that equipment has been seismically qualified. ___ 1708.4 12. ❑ Obtain system tests as required by ASCE 7 Section ___ -__ --- 1708.5 17.8. SpecialnspectionForm_2012.doc revised 09/06/12 County of Santa Clara Department of Environmental Health Consumer Protection Division 1555 Berger Drive, Suite 300 San Jose, CA 95112-2716 (408)918-3400 FAX (408)258-5891 www.EHinfo.org Board of Supervisors: Cindy Chavez, Mike Wasserman, Dave Cortese, Ken Yeager, S. Joseph Simitian County Executive: Jeffrey V. Smith March 4, 2016 Golden Property Development Attention: Mike Ramirez 10 South Grant St Roseville, CA 95678 PROJECT NUMBER: PROJECT NAME: PROJECT ADDRESS: SR0846781 EUREKA BURGER 19369 STEVENS CREEK BLVD STE 300 CUPERTINO Dear Mr. Ramirez: Drawings for the above project have been reviewed and approved by this department, subject to the following conditions: • This approval is for the change of both Type I exhaust hoods only. The conditions listed on the original approval letter dated 8/20/16 still apply. • All construction must be completed according to the approved plans. Contact our office for review and approval for any changes to the approved drawings, including structural and/or equipment changes. This approval shall expire by limitation and will become null and void if the construction, reconstruction, alteration, or other work authorized by this approval is not commenced within 180 days from the date of approval. Please retain one copy of the approved drawings on the job site. A FOOD FACILITY CONSTRUCTION CARD has been attached to the job copy and must be posted with the other building permits. Present at least two (2) copies of the drawings to your local building official for the required permit application and approval. Any change to the drawings as a result of reviews by other jurisdictions must be brought to the attention of this department as soon as possible to avoid construction delays. Please be advised that you are responsible to contact this office to arrange a construction inspection before rough plumbing signoff, installation of equipment, and upon completion of the project. The original submittal fee(s) includes up to three (3) inspections. Additional fees may apply to any further inspections or site visits. In the event the project is not ready for a scheduled inspection, please provide at least 24 hours advance notice to avoid additional charges for canceled inspections/missed appointments. The Final Inspection for the project cannot take place until the balance for all Plan Check-related work is PAID IN FULL, and the enclosed Application for a Permit to Operate has been completed and is on file with this office. Failure to meet these requirements will result in the cancellation of the Final Inspection. Please note: Rescheduling will be subject to availability. Absolutely no food storage or food preparation will be allowed onsite until this department issues you your Permit to Operate. This permit will be issued upon the successful conclusion of our final construction inspection. You will also be asked to submit a performance test of the mechanical exhaust system, if one is present, and verification of garbage collection before the issuance of the Permit to Operate. This food establishment will be required to have either the owner or an employee successfully pass an approved and accredited food safety certification examination. This certification must be obtained within sixty (60) days after your Permit to Operate is obtained. Contact this Department for more information. In addition to food safety certification (with certain exceptions) all food handlers are required to obtain a food handler card within thirty (30) days of hire. Contact this Department for more information. If you have any further questions or would like to call for an inspection appointment, please contact the Department at (408) 918-3400, between 8:00 a.m. and 5:00 p.m., Monday through Friday. Very truly yours, Kane Bethea, REHS Senior Environmental Health Specialist Plan Review and Construction Unit Enclosure cc: City of Cupertino Building Department Owner