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09060134 - PUB=ileEdit Actions Details Links Favorites Help Permit Information Permit Number " 90 060134, Status' vI Master Number Notes i 1 Project Apply Date 06/23/2009 Operator patg Permit Issue Date LQ8/11/2009-Operator patg I Certificate Issued 09/03/2009 Operator PALM Certificate Type Certificate Number I Permit' PropertyZoning Applicant i Contractor ' !I Defined Fields Permit Details Permit Type ' 118 TI Location It4orrnation Address " ' 10041 N 8LANEY AVE City/State/Zip CUPERTINO APN 31623036.00 Unit Owner Entity Information CA 95014 Owner Name' rSYLVIA DUONG HANG INC — Use Default ❑ Address Home -1548 CLARITA AVE - - - -_.. City/State/Zip SAN JOSE CA 95014 TENANTIMPROVEMENT Usage Class' IIAII B, IIIIIIB,IVHTV8NEW Applied Value ' �— 226101 SQUARE FT. 0 Calculated Value 0 US C-404 Type 437 (I ALT: NON-RES, NON-HSKPG Permit Form' AUTOPERM - PERMIT v Ownership 1 - Private Project Size STANDARD - STANDARD v' 'ermit issued 08111/2009 Inter permit status Purpose/Special Conditions - — - ---- - COM'L TI-Q MART- NO ELECT, NO LIGHTNG, REPLACE (EXISTING EQUIPMENT, FOOD PREP FILMED- 2011 W [QAdd Default T v 10OK Back Ln Contractors Fees Plan Reviews l Inspections (! Print Permit Le Adjustments Holds l Copy Permit lClose Permit Overrides ` l!-!N Supplemental Fields 1 1, Notes t) Attachments CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10041 N BLANEY AVE CONTRACTOR: TBD -TO BE DETERMINED PERMIT NO: 09060134 OWNER'S NAME: SYLVIA DUONG HANG INC DATE ISSUED: 08/11/2009 OWNER'S PHONE: 4086793821 , PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r— r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.f! f r MECH RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:COM'L TI-Q MART- NO ELECT, NO LIGHTNG, (commencing with Section 7000) of Division 3 of the Business & Professions REPLACE Code and that my license is in full force and effect. EXISTING EQUIPMENT, FOOD PREP 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $22610 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: 31623036.00 Occupancy Type: APPLICANT CERTIFICATION 1 certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs, and expenses which may accrue against said City in consequence of the 180 DAYS FROMiT CALLED INSPECTION. 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. 7 Issued by: F /� O 1 Date: Signature Date C1� OWNER -BUILDER DECLARATION RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection, I agree.to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1 hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self -insure for Worker's 1 have read the hazardous materials requirements under Chapter 6.95 of the Compensation, as provided for by Section 3700 of the Labor Code, for the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & I have and will maintain Worker's Compensation Insurance, as provided for by Safety Code, Section 25532(a) should 1 store or handle hazardous material. Section 3700 of the Labor Code, for the performance of the work for which this Additionally, should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 1 certify that in the performance of the work for which this permit is issued, I shall Health & Safety Code, Sections 25505, 25533, and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of Ca!ifornia. If, after making this certificate of exemption, I Owne • or auth9 'zed agent: O become subject to the Worker's Compensation provisions of the Labor Code, 1 must G Date: forthwith comply with such provisions or this permit shall be deemed revoked. �/CONSTJJTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued (Sec. 3097, Civ C.) correct. I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save Lender's Address 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 ARCHITECT'S DECLARATION with all non -point source regulations per the Cupertino Municipal Code, Section I understand my plans shall be used as public records. 9.18. t �l� G ' IGI C Licensed Professional Signature Date �� CITY OF CUPEkTINO CITY OF CUPERTINO TENANT IMPROVEMENT PERMIT APPLICATION FORM APN # 3 3 ® 3 co Date: Building Address: N U Mailing Address (if different from ilding address): CPt q 5 Tenant H (If tenant please provide a letter from the building owner approving the tenantImprovement.) Building Owner Tenant/Building Owner's Name: Phone #: Contractor: Phone #: A H A t U 11/1 rJ J U Con sfU1016 N Fax #: •� 3 Contractor License #: $ � 2 $ (� Cupertino Business License #: 3 0 9 Q 2- Contact: -T +W " 7W ROUYSN Phone #: 408 g23-7-z ) - /- Fax #: (40523 Alternate Contact: Phone #: (4W r,-7 9 _ 332 f Fax #: 2 y 3 76 Valuation (cost of project): 2 2 j C� 10, 42 Job Description (be specific): -T T cc nil t! C Ccc, fU 0 let-_-Y J'c,ct, (V o l� �► �i t� Re (cite c,( roc i s-j �'v� ten9u,l- y;1eP -f w pry - Tenant Im ovement Includes Re -Roof. Yes ❑ No 0 If yes, number of squares Tenant Improvement Includes Structural Yes ❑ No Qf Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V-B NMC F_/ 01W 0?,'y Project Size: Express Standard Large Major Green Building: Please complete Leed for commercial interiors checklist & attach it to the application or if applicable, include in plans & sheet index LEED Points Achieved *** For Office Use Only*** Over The Counter ❑ Revised 01/07/09 CITY OF CUPERTINO TENANT IMPROVEMENT FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type IATINSP Tenant Improvement B 1A TI Inspection IATIPLNCK Tenant Improvement Plan B Check z: 1BTIINSP Tenant improvement B 1B T Inspection 1BTIPLNCK Tenant Improvement Plan B Check IETIINSP Tenant Improvement B 1E TI Inspection Preschool IETIPLNCK Tenant Improvement Plan B Check -Preschool 1FTIINSP Tenant Improvement B 1F TI Inspection Facto/Indust 1FTIPLNCK Tenant Improvement Plan B Check-Factory/Indust 1HTIINSP Tenant Improvement B 1H TI Inspection -Hazardous 1 HTIPLNCK Tenant Improvement Plan B Check -Hazardous IITIINSP Tenant Improvement B 11 TI Inspection -Institutional I ITIPLNCK Tenant Improvement Plan B Check -Institutional 1MTIINSP Tenant Improvement B 1M TI Inspection -Merchandise 1MTIPLNCK Tenant Improvement Plan B Check -Merchandise 1 STIINSP Tenant Improvement B 1S TI Inspection -Parking Garag 1 STIPLNCK Tenant Improvement Plan B Check -Parking Garage 1 REROOFCOM Re -Roof Commercial B 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES f Commission Fee 1 1BSEISMICO Seismic Commercial B BUS LIC Business License B UT"' 1 2 of 2 P/ .,13 Lct'C_f<