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15060160CITY OF CUPERTINO BUILDINNG PERMIT ! BUILDING ADDRESS: 19409 STEVENS CREEK BLVD CONTRACTOR:ILAKEVIEW PERMIT NO: 15060160 CONSTRUCTION. OWNER'S NAME: MAIN STREET CUPERTINO AGGREGATOR 10505 CORPORATE DR DATE ISSUED: 09/14/2015 p ER'S PHONE: 3109629189 PLEASANT PRAIRIE, WI 53158 PHONE NO: (262) 857-3336 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL F1COMMERCIAL El PIEOLOGY STE 140 -MAIN STREET- T.I. TO BUILD OUT License Class Lic. # SHELL FOR (N)STAURANT (2,187 S.F )(FLEX 2) Contractor Date c f . REV # i - REVISEI WOMENS RESTROOM, KITCHEN LAYOUT INCLUDING GREASE . TRAP & AIR INTAKE/VENTILATION - ISSUED 10/26/2015 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: Sq. Ft Floor Area` Valuation: $250000 1. I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. 1 have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 31620109.19409 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION PERMIT,, EXPIRES IF WORK IS NOT STARTED I certify that I have read this application and state that the above information is WITHIN 180 DAYS OF PERMIT ISSUANCE OR 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 180 D S FROM LAST CALLED INSPECTION. upon the above mentioned property for inspection purposes. (We) agree to saveg. indemnify and keep harmless the City of Cupertino against liabilities, judgments, e W04Date: i costs, and expenses which may accrue against said City in consequence of the Issued bk4p y: granting of thi ermit. AV/96/06- dd ' ally, the applicant understands and will comply with all non-poin so rce regulat" n per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signature Date ! 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 ® OWNER -BUILDER DECLARATION inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Appli ant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1. 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) HAZARDOUS MATERIALS DISCLOSURE 2. 1, as owner of the property, am exclusively contracting with licensed contractors to hazardous under Chapter 6.95 of the construct the project (Sec.7044, Business & Professions Code).25533, I have read the materials requirements California Health &Safety Code, Sections 25505,25533,and 25534. I will maintain compliance with fhe Cupertino Municipal Code, Chapter 9.12 and the Health & hereby affirm under penalty of perjury one of the following three declarations: Safety Code, Section 25532(a) should I store or handle hazardous material. 1. I have and will maintain a Certificate of Consent to self -insure for Worker's Additionally, should I use equipment or devices which emit hazardous air Compensation, as provided for by Section 3700 of the Labor Code, for the contaminants as defined by the Bay Area Air Quality Management District I will performance of the work for which this permit is issued. maintain compliance the Cupertino Municipal Code, Chapter 9.12 and the 2. 1 have and will maintain Worker's Compensation Insurance, as provided for by Health & Safety Co eetions 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. O r uthor�� 060—.4 GDater s. 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 I hereby affirm thht there is a construction lending agency for the performance of work's must forthwith comply with such provisions or this permit shall be deemed for which this perinit is issued (Sec. 3097, Civ C.) revoked. Lender's Name Lender's Address APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION correct. I agree to comply with all city and county ordinances and state laws relating j to building construction, and hereby authorize representatives of this city to enter I understand my plans shall be used as public records. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Licensed Professional costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date CONSTRUCTION PERMIT APPLICAI COMMUNITY DEVELOPMENT DEPARTMENT - BUILDIW 10300 TORRE AVENUE - CUPERTINO, CA 950014-3255 Ci.lPERTtNO (408) 777-3228 - FAX(408)777-3333 - buildiinn(g@cu'rledino, M t,tatrr rntoe•rtsrrrvrrrn.r n An11l1Trnli 1 r 1 AT TRUATTAW I Ti 17Gc -fifrVTSTON 1 01UGINAL PERMrr 015 "0(001 &0 PRGIECr/pADDRESS I ! yQ tp _57rUE,S CgSA, sp� �r Arrla CON O OWNERNAME t 1 � PIZ2eWr+ � PHONEggq� et;;m. 7�A17u7d'MTZ.�O FrbIAtL i�tt l e/��ft0/o . Lloh . `FAXo�E�I�y STREETADDRESS —o 7,qz .�16 �'N'tN C- Jt%GHO U .. d1 � +-. -7e ZSR t. coNT.\CT NA6tL•' j1„th%�_PHONEoyG.. OCc. Ekt3.. 83 N", �l� ti MAILJ;, ritx�.e .t��CJr7a .Gct7. STREE7ADDItGSS3c3ZYZ/i�s�'�KftN21� '(A� �.saATt:7ZitpCLL; ,ucaft�tl�ca cit 9 Zlii�P7e F'�` tom- 769ef 9`ir`i- 0 OWNER ® Ow- L,M BUILDER ® OWNER AGEW ® f.ONTpkcr R ❑ coNTRACrOR AGLNT 13 ARCHITECT ® ENGINEER ❑ DEVELOPER XTENANT CON O � LTTYP Low-nav, f(N�-Loi7rf=rG f71. S '7 {1 N Aird t' 'a IST i� DU d't� f'tF't•�' G' Da?P tIJ ..[ISE C- lOZS USESi++u f J - SfG�RIES ' ... TYPE OCc. SOX.T. NAMh t uc�lon '(A� 4BUS.LICA JVC0i6 FA? t V Vii BATHROOM KCTCKEN OTHER - 11MMI)ELArtFA RFMOORL AUEt REMOARLAREA $TRE R S � ( A if d PHGN d ARCiITECC2Nc[NEERNAME A LCNNMR -71 �ovS.Ff�c"e BUS. LIC # COMPANY NAME E-MAILb}7atlii GQ /rd�'ftGFG� r t 7t'CN+C i FAX S7RELT ADDRESS' 7�/ c%K�e �,U�'2�w,, CITY, STATE, 21P oEf Q PLAMRNGPIANREVIEW t/ pir—icanoo (�ww7�•. r `^d %�iU�% t=a S /g1 �E- �'� tO if �S DESCRIPTION OFwO1tK' /41iD A SStIU AW Low-nav, f(N�-Loi7rf=rG f71. S '7 {1 N Aird t' 'a IST i� DU d't� f'tF't•�' G' Da?P tIJ ..[ISE E.Y1S'9Tt:OUSEED AA lOZS USESi++u CON R. TYPE � g - SfG�RIES ' ... TYPE OCc. SOX.T. VALUATION ($) =TO 2l pis(— NEW AREANLOO r� ©AREA —^ �4- AL NEMO �Er AREA C.i v - SF' - - BATHROOM KCTCKEN OTHER - 11MMI)ELArtFA RFMOORL AUEt REMOARLAREA N DWELLINU UNITS: is I aac.DDE vasaa l3 No ,.. .... ... - BEING ADDED? ❑NO AQDr[10N? ®NO PRC -APPLICATION ❑YES IF YES, PROVIDE Ct)k'YOP IS'3'llE lit.DG AN ❑YES _. -Y. TOTAL VAI.tfAiTOP:: PLANNING APDL # ONO rI %NN1NG APPROVAL LF'rrER EICHLER HOME;? I By my signature below, I certify to each of the following: I am the roperty Owner o act on the pro owner's behalf. t have read this application and the inforntntion I itavcprovidcd is corrocL 1 hav the Descrip o of Work and erify it is I agree to comply with all applicable local ordinances and state laws relating to bW g co truction. I Dtati of Cupertino� er rho above -identified property for inspection purposes.. Signature of ApplicanciAgent Ipato; (,J$ New SFD or Multifamily dwellings: Apply for demolition permit for 0 ovER-� a rcovNrER ❑ Bumum"AN REVIEW _ existing building(s). Demolition permit is required prior to issuance of building ❑ Q PLAMRNGPIANREVIEW permit for new building. ZXPRI� Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ElSTANI ARP 13PUBLIC WORKS _ form. if any Hazardous Materials are being used as part of this project. n LARG� p gIRB DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ M"O D sA,IrrastY sEVWErtDlsTtucT submittal of Building Permit application. nU.m,nwiwatrV rAr. rtRAI CTI BldgApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 19409 STEVENS CREEK BLVD 7D -ATE: 10/12012015 REVIEWED BY: MELISSA APN: 31620109.19409 BP#: *VALUATION: Iso PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY PENTAMATION USE: Commercial Building PERMIT TYPE: WORK REV # 1 - REVISE WOMENS RESTROOM KITCHEN LAYOUT INCLUDING GREASE TRAP & AIR SCOPE INTAKE/VENTILATION liecja. Plan ("lieek 1,171tr2b, Eke, f' w. Clwek Pe<:i2. !'r>,,r2rt i°'ee: 1'1 r7z,.,. tie 7a .F Fee: .0 c. Per lrrr tee: litSh.LJ L (>rl2vr 1't2+Fr& Lsiz, 01rc:r' Elec. /rash. Ifech. hup. Fee:f Plumb. 1 sly fazze: 1 lea Ins'), 1 ee., NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School .4 i .. , nn.7i nL. ociiassnto rantart tho Dont far addn �l info L LJLI LLL, GLL.• 1 /ccuc. ccu wc L/Lwcw .vac L.cL •a.•,•,••w,w. FEE ITEMS Fee.Resolution 11-053 E . 7/U13) ( f�T v.r.,............._.--___—�______________ FEE QTYIF E __.. _._ MISC ITEMS Plan Check Fee: $0.00 j Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (E)Reg. 0 OT F0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee -.(E) Reg. OT Q•Q hrs $0.00 I PME Unit Fee: $0.00 PME Permit Fee: $0.00 Co:ZStruelion TIx: t f9inis'tt'd, tine Fee: ;.. 01 E Work Without Permit? 0 Yes No _ $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure O � Tr avel.Doe,uraeruadon Fees: Strong Motion Fee: $0.00 1 I# $859.00 Revisions 1REVCOMTI Tenant Improvement Bldg Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $859.00 ;= = T(�fiA:TEE: $859.00 I'CCVMUU. l U,v uw — CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19409 STEVENS CREEK BLVD CONTRACTOR: LAKEVIEW PERMIT NO: 15060160 CONSTRUCTION OWNER'S NAME: MAIN STREET CUPERTINO AGGREGATOR 10505 CORPORATE DR "DATE ISSUED: 09/14/2015 OWNER'S PHONE: 3109629189 PLEASANT PRAIRIE, WI 53158 PHONE NO: (262) 857-3336 LICENSED CONTRACTOR'S DECLARATION JOS DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ PIEOLOGY STE 140 -MAIN STREET- T.I. TO BUILD OUT SHELL FOR RESTAURANT 2,187 S.F License Class Lc. # � � (N) ( )(FLEX 2) Contractor Date IS (5 P -r ) Ll 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: 1. I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point sourc ser the Cupertino Municipal Code, Section 9.18. Signature!]A ' 90IS ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: i. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: t. I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 3. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date Sq. Ft Floor Area: Valuation: $250000 APN Number: 31620109.19409 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS 180 DAYS F T ISSUANCE OR ED INSPECTION. Date: RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owr • authorr eSR.t" e:_ 9 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 0 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 FAX (408) 777-3333 • building(cDcupertino.org NEW CONSTRUCTION [ ADDITION X❑ ALTERATION / TI ❑ REVISION /Soho/6O 1 ynr�nRED ORIGINAL PERMIT # PROJECT ADDRESS 19409/Stevens Blvd, Suite 140 7APN# _314 _70 _ !US� �� '//) -7 �ICreek OWNER NAME/� r/Ll' 77%0 a ;-4 �V' � PHONE X310}962-9189 E-MAIL hmilberger�a pieology.com STREET ADDRESS liS/ J& Z10d -e-. STATZ�P �I� CONTACT NAME Hans Milberger PHONE (310)962-9189 I E MAI hmilberger@pieology.com STREET ADDRESS 30242. Esperanza CITY, STATE, ZIP Rancho Santa Margarita, CA 92688 1 FAX (949)858-7825 ® OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT '❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER TENANT CONTRACTOR NAME 'TO BE DETERMINED't*'F LICENSE NUMBER LICENSE TYPE BUS. LIC# ' COMPANY NAME E-MAIL .FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEERNAME Peter S. Macrae, AIA LICENSE NUMBER C-28571 BUS. LIC# N/A COMPANYNAME. N/A E-MAIL pmacraeQa macraearchitecture.com FAX (614)848-8113 STREETADDRESS 74 Orchard Drive CITY, STATE, ZIP Worthington, OH 43085 PHONE (614)205-6805 DESCRIPTION OF WORK Tenant improvement project to develop a newly constructed retail space into a pizza restaurant, including' dining area, front line, commercial kitchen and restrooms. K t 1� _.EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES none restaurant II -B 1 USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG AREA 2,187 sf NEW FLOOR AREA n/a DEMO AREA n/a TOTAL NET AREA 2,187 sf BATHROOM - KITCHEN OTHER REMODEL AREA REMODELAREA REMODELAREA PORCH AREA DECK AREA I TOTAL DECK/PORCH AREA GARAGE AREA: FIDETACH' ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? []NOADDITION? ONO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YE D $Y'' OTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? 0. (J By my signature below, I certify to e ofthe following: I am the property owner or a agent t properly owner's behalf. I have read this application and the information I have rovided is correct. I have read the Description of Work it is accurate. I agree to comply with all applicable local ordinances and state laws relaGni to uilding construction. I authorize representatives of Cupertino to enter the above ' ntifie roperty for inspection purposes. ®� Signature of Applicant/Agent: Date: SUPPL TAL rNVOMFATION REQUIRED Q ' RI>AN CHECiCTyPE,. ROUTING SLIP ❑ ovER xHcourE Z AQ Buu DING PLAr31Y>Ew _ New SFD or Muli amily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. I� 'EXPRESS B:E44EW X Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ( sS`i"Alkp ." ❑ VUBLTC tORKs form if any Hazardous Materials are being used as part of this project. ❑ F7E LARGE: DEPT Copy of Planning Approval Letter or Meeting with Planning prior to MAJUx' fl sANi7rARX$1RD15TRiCT submittal of Building Permit application. EIWiR0,NMENTALJ EAL = BldgApp_201 Ldoc I•evised 06/21/11 CITY OF CUPERTINO FFF. FgTTMATnR _ R7TT7 .nI1V(_ 11-A71[C1rnXT = 19409 STEVENS CREEK BLVD DATE: 06/25/2015 REVIEWED BY: MELISSA _[�ADDRESS: APN: 31620109.19409 BP#: > VALUATION: $250,000—� *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement URSIEMARY Commercial Building 2,187 PENTAMATION PERMIT TYPE: 1A TI WORK MAIN STREET - PIEOLOGY - BUILD OUT SHELL FOR N RESTAURANT 2 187 S.F SCOPE PME Plan Check: OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID A (Tenant Improvements) II-B,111-B,IV,V-B 2,187 $2,499.39 IATIPLNCK $1,294.95 ]ATIINSP PME Plan Check: $0.00 Permit Fee: $1,294.95 Suppl. Insp. Fee: Reg. 0 OT 0,0 hrs $0..00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ('012struction Tax: TOTALS: 2,187 $2,499.39. Administrative Fee: $1,294.95 M N',CH, I()URLY Yes. _ No PI ;Ui1IB, HI}UR)E;Y = Yes i•9e<:h i., {°tit f. Ia c,' P1.11111b. Platt l!s>clt. fhch Alec. Pl<r (,',heck Pcpmit Fee nvz Fee: Elt c. Permit Fee: C')The? :11e: •h. irt:st�. OtherNumb Irs . {?r/zea 1 tcc. lnsr;. ilcr•'z. la v..). Lope: Phsntb. Trzsl�. Fee: fliec. lrsfs. Fee: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School 11 Orirt_ otr_ 1_ Thoco foot nro hn—i — ihn —1....., —A, -- .,..i0....i., /T ,..i . i i&., n ..i ! ,...A.7., yl ;"Irf FEE ITEMS (Fee Resolution 11-053 E f.' 711/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,499.39 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (E) Reg. Ci OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,294.95 Suppl. Insp. Fee: Reg. 0 OT 0,0 hrs $0..00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ('012struction Tax: Administrative Fee: C E) Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure E) 0 Strong Motion Fee: IBSEISMICO $70.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $10.00 UBTfiyTAL, $3,874.34 $0.00 IC3TF $3,874.34 Revised: 05/07/2015 CUPFRTINO TEMPORARY CERTIFICATE OF OCCUPANCY FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 950143255 14081 777-3228 • FAX (408) 777-3333 • building a()cupertino.org ilCb ai�ao1b APNC%&0 I DATE:VALLUATION: FLOOR AREA OCC LOAD LEVEL COMMENT SITE ADDRESS: i C @ �,��`.s ' — OWNER'S NAME: /% PHONE #&A9 FAX #: 6 14 MAILING ADDRESS (if different%pffi CONT ACT R: PHONE #: �a/L�7, FAX #: CO AC : PHONE -?6 FAX #: TCenonDADV CGRTIFI(-ATF nF nr—nUPANCY INFORMATION BOND TYPE: ❑ SURETY BOND AMOUNT (1 % VALUATIONC66(BLDBONDS] CODE � ❑ CHECK [:1 CASH BOND OF BOND: 5K min -10K max $ EDITION: TCO EXPIRATION I , n F � FEE: $2$6,00/mo TOTAL FEE: $ 5 [1TEMPOCC] DATE (6 MONTHS MAX): Q� f��l USE TYPE OF CONSTR FLOOR AREA OCC LOAD LEVEL COMMENT ire �j 1 / g /r�� Si nature.......C'.........'........�1..,.'.......... — : D e:/ ❑ APPROVED ❑ APPROVED WITH CONDITIONS - Public Works ❑ APPROVED ONDITIONS- ❑ APPROVED WITH CONDITIONS - Signature:................................................... Signature: ..... _ Date:...................... �� // Date:/....` J APPROVED APPROVED WITH CONDITIONS` ..r��rn n�nAOT"MKIT 1 At-_CKIl-V ADDDnVAI C• Planning ❑ APPROVED ❑ APPROVED WITH CONDITIONS* Signature: ......................................................... Date:........................ ire �j 1 / g /r�� Si nature.......C'.........'........�1..,.'.......... — : D e:/ ❑ APPROVED ❑ APPROVED WITH CONDITIONS - Public Works ❑ APPROVED ONDITIONS- ❑ APPROVED WITH CONDITIONS - Signature:................................................... Signature: ..... _ Date:...................... �� // Date:/....` J APPROVED APPROVED WITH CONDITIONS` nature: -.... Signature: ........ *CONDITIONS' F 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 of the bond may be forfeited and the non-compliance may result in an enforcement action. Owner Contractor Signature: ......................................................... Date:........................ Signature:. .. ....... .. Date:/o7 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 Temp0ccForm_2013.doc revised 717114 i i U /�Il� ��� ` Ql� f - g�� CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: / PERMIT # /,O 601 OWNER'S NAME: !'fj�© Csi'n?PfC��ip� PHONE # GENERAL CONTRACTOR: et/1Gl.J �Ccry� i.1 BUSINESS LICENSE # r ADDRESS: Electrical] CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL 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 6/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Csi'n?PfC��ip� 3lns$(j Cement Finishing�+��� �Ccry� i.1 i Electrical] Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing ` ��� S_ -S Heatingu� At V,, Insulation Landscaping Lathing Masonry Painting / Wallpaper a,e n A- Paving Plastering Plumbing Roofing e' A 350 Septic Tank Sheet Metal u ' /?/'� dsl1 - jam Sheet Rock +C. � T Tile Owner / Contractor Signature Date