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15110017P2 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19620 STEVENS CREEK BLVD CONTRACTOR: SMI CONSTRUCTION PERMIT NO: 15110017 INC OWNER'S NAME: EVERSHINE VI, LP 595 MONTAGUE AVE DATE ISSUED: 11/03/2015 OWNER'S PHONE: 4089301275 SAN LEANDRO, CA 94577 PHONE NO: (510)351-3288 lep LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class t3 Lic. #__D_Z5 It 66 MAINFIELD MANAGMENT (STE # 290)- T.I. TO CREATE (N) BREAK ROOM (NO FOOD SERVICE) (165 S.F.) Contractor. �01i fOn57ctc t w� i✓rc. 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: $1500 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: 36906010.00 Occupancy Type: 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 upon the above mentioned property for inspection purposes. (We) agree to save 180 DA F A�ALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, __ costs, and expenses which may accrue against said City in consequence 1111 granting of this permit. Additionally, the applicant understands and will co t�� _ Date: with all non -point source regulatiots per the Cupertino Municipal Cod , 9.18. Signatu _ Date P/,10 RE -ROOFS: All roofsinspected prio�to y roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ® OWNER -BUILDER DECLARATION 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, 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) 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 Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent Date 14103,M 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 CONSTRUCTION LENDING AGENCY 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 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, 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 - - -- CONSTRUCTION PERMIT APPLICATION! COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 98014-3255 r (408) 777-3228 • FAX (408) 777-3333 - buildina(a.cupettino.ora / I CUPERTINO ( ! 7 -KTF.W ('.nW CTRT V"TTC)Ni F-1 dT-)T-)T-rTr)'fJ 7rt T Tca 7,11111 l ^r I7 nrTrrotnwT T rt�c a�r> r, ter a r PROJECT ADDRESS F g% 9 4PN OWvERNAl ` I PHONE 'T-I✓SIL (EIJU) Z,-7 STREET ADDRESS 5� � � I CITY, STATE, ZIP I FAX '�' ca r®�ti , C A- CONTACT NAMME PHONE E•MAII. /ya STREI~T ADDRESS CITY, STATE, ZIP FAX ❑ OWNER 0. OWN'EP.-BUILDER 13 OWNERACENT 5 CO?1'TR0.CTOR 13 CON'I'RACTORAGENT 13 ARCHITECT ❑ BTIGLN eR ❑ DEVELOPER ❑. T-.NANT CONTRACTORKA IE LICENSE NU USER LICENSE TYPE BUS. LIC t as vvaI ell COM?ANY NA.hS > _ i /' � ✓+.T'e rK-mil G' Ve L` . E-WLSIL .L fra. •7c/•p7. A`J�i7 BA.S��— •`^'La a0. Gw.-+ FAX ., g y 'f &. STREETADDRESS 5 c l� t� �. � �� CITY, STATE, ZIP 5 G ,� -a �� �� PHONES, ( �� v. 35r 32—ey ARMTECTrNGIIvLFR NP.WE LICENSE NUW.BER '� BLTS. LIC ff COMPANY N U\0 y E :M SL to �.i C�°j`B't✓YG'�'d� :�.� � �.,1 Cr�'®S"�i�taC7' '�G2 � B'6c &lv�+- e�.o-. FAX lr�i'� �jd �.��®� STB.I ET ADDRESS CITY, STATE, ZIP I P$OPTE I. of tilt -7-7 DESCRTP T ION OF W ORK hep E70STLNG USE - PROPOSED USE CONSTR TYPE 4,STORIES F= ;LCL oe �e;e AI�1 I 6 V - e3 USE Ilf TYPE ( OCC. ( SQ.FT. I VALUATION (S j EXISTG AREA 300 N W FLOOR I AREA ® S -f- DE1`40 I. AREA �,5- fc TOTAL NTtT AREA I BATHROOM KITCHE14 OTHER RaMODEL AREA REEMODEL AREA REMODEL AREA 1��" S•¢- - L I PORCH AREA DECK AREA TOTAL DECK/PORCH fiR A GARAGE ARBA: DETACH I ATTACH I I I 9Dq+£I.LAGWITS: ISASECOND UNIT❑Y£S AD£D? AJ SECOND STORY ❑YcS ADDITION? �10 -)DED? .�0 PREE-APPLICATION l] YES IF YES. PROVIDE COPY OF ( PPL,- O PLANTNaGAPPROVAL LETTER PLANNTDNGA� IS THE BLDG ANEO EICHLERHOME? A _M. ._._�� ��- � TOTAL VALUATION: NO By my signature below, I certify to each of the following: I am the property oxvner or authorize anent to act n t pope ov tier's behalf. I have read this ' application and the information I have provided is correct. I have read the Description of'Work and ven > i curate. I agree fo"comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives -of Cupertino t er the above -identified property for =-1-.ct` purposes. /1771 Signature of ADpIicant/Agent: Date: 3 X,/,g ✓ Z%;' SUPPLENfENTA 4ATION REQUIRED s c cx .P> m OY`ER`TH�COL-hTERy��BDILDL'�GPLA3�TZ2ES'IE•FY New SFD or \1ultifamily dwellings: Apply for demolition pe. reit for existing building s). Demolition permit is required prior to issuance of building � � j � � - T permit for new building.s� 0: 0070 � =OEM Bldgs: Provide a completed Hazardous AZaterials Disclosure IrA �W �-: _Commercial form if any Hazardous hdaterials are being used as part of this project. �r F Co of Planning Approval Letter or l�2eetir.Q with Planning prior to Py PP �Y submittal ofBuildir!gPermit application. nsAaoR �R SEER DTsRrcr �._.�'�"f� �'�'m'" ��g`�--'_E?�z�xoz�'?✓,;;nraz.I�Avxa,�:_� BId.aApp_MJ.doc revised 06121/11 CITY OF CUPERTINO ,;' FEE ESTIMATOR BUILDING DIVISION y`- ADDRESS: 19620 STEVENS CREEK BLVD DATE: 11/0312015 REVIEWED BY: MELISSA APN: 369 06 012 BP#: 'VALUATION: 1$1,500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant improvement PRIMARY Commercial BuildinT_ USE: g -g PENTAMATION PERMIT TYPE: 1 GENCOM WORK MAIN FIELD MANAGMENT STE # 290)- T. 1. TO CREATE N BREAK ROOM NO FOOD SERVICE SCOPE (165 S.F.) 'M.X„ °' ubSkYZE{l - �-� 'r` s'�� - tfi �. a„ _ �3T- K: x .=e fn 4 az m kK a �,x F. a Fi: e >> �m ��Ll:. �•`x N 4',%2,-,... Y,a';.i:,G q � �a..� _....� ,e a:�i,_ _ � cM^'c ,_ _, _<, , ., -. ,� _, �_ ...�. a,^= . __ .m �.Ya. wrxM�w s�ivH..li:=_:..M v. .7 `J.. 'k h,`l e... A0,t i // 'he ck t•liyc:''a.3C7"?Yit..i°tii.'; jiP%df".:js:'i'T'i?f"'{:'i:`: I:.l£'.c', 1}£�z`tr�tj°z'E;: / 1 F-1 I) /. rj£tY` I St,41}, zr.,.Fr. inso. P,rrrnli.:.ft:+,... z=,>t:: ix:.sj, NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public works, Pire, Namtary Fewer u'sj ca, acnuuc Wwirirf. ofn 1 Thoea foot ora hnead n» tho nralimi""ry infnrmnfinn avnilahly and aro nnly an estimate. Contact the Dept for addn't info. FEE ITEMS (Fee Resolution 11-053 EE. 7/U13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes No $0.00 2 hours $286.00 Plan Check, Hourly ISTPLNCK Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. Fee-. Reg. 0 OT o. hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ;qqr: sst uc:iii r l'�x. ohninivralive G Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential G Building or Structure 0 ir141vel l.�£3L°ume1'mytion �`c.eF v Strong Motion Fee: IBSEISMICO $0.50 2.0 hrs $286.00 Inspections ISTINSP Inspection, Hourly Bldg Stds Commission Fee: IBCBSC $1.00 a F ST�BT©TALSY' _.... $1.50 $572.00i�o $573.50 Kevisea: tuluiizuio CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19620 STEVENS CREEK BLVD CONTRACTOR: SMI CONSTRUCTION PERMIT NO: 15110017 INC OWNER'S NAME: EVERSHINE VI, LP 595 MONTAGUE AVE DATE ISSUED: 11/03/2015 OWNER'S PHONE: 4089301275 SAN LEANDRO, CA 94577 PHONE NO: (510)351-3288 0 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL F1 COMMERCIAL F1 MAINFIELD MANAGMENT STE # 290- T.I. TO CREATE (N) License Class Lia. # $ 3 l / 6$ BREAK ROOM (NO FOOL) SERVICE) (165 S.F.) Contractor S►t'X Date 12/b,'(15 DEF # 1- REQUIRED ADA DETAILS FOR (E) RESTROOMS & ELEVATOR. 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $1500 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 APN Number: 36906010,00 Occupancy Type: permit is issued. 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 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 permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. ~^ RE -ROOFS: Signature / Date /ZJta' l 1 S All roofs shall be inspected prior to any roofing material being installed. If a roof is inspection, l agree to remove all new materials for installed without first obtaining an inspection. OWNER -BUILDER DECLARATION Signature of Applicant: Dater - I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, do the work, and the structure is not intended or offered for sale (See.7044,- will Business & Professions Code) HAZARDOUS MATERIALS DISCLOSURE 1, as owner of the property, am exclusively contracting with licensed contractors to hazardous requirements under Chapter 6.95 of the construct the project (Sec.7044, Business & Professions Code). I have read the materials California Health & Safety Code, Sections 25505, 25533, and 25534. 1 -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 Health & Safety. Code, Section 25532(a) should I store or handle hazardous declarations: 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 by Bay Area Air Quality Management District I Compensation; as provided for by Section 3700 of the Labor Code, for the air contaminants as defined the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and performance of the work for which this permit is issued. the Health & Safety Code, Sections 25505,25533, and 25534. I have and will maintain Worker's Compensation Insurance, as provided for by Date: Section 3700 of the Labor Code, for the performance of the work for which thisOw mer or authorized agent. 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code, I must work's for which this permit is issued (Sec. 3097, Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is county ordinances and state laws relating correct. I agree to comply with all city and 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, said City in consequence of the I understand my plans shall be used as public records. costs, and expenses which may accrue against 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 - - -- CONSTRUCTION PERMIT APPLICATION CONddiUM t Y DEVELOPIViEN T DEPAR NAEN T • BUILDING DIVISION 10300 TORRE AVENUE • CUPER T INO, CA 85014-3255 (408) 777-3228 • FAX (408) 777-3333 - buildinolcucunerino.orO CUPERTINO f�--i t,TzW COIvSTRUmoN u ADDmoN ❑ rj=—,kn ?� /iI L"I REQISION DB: t = O IGII�kT PE 51l t9D t 7' PRbieCl ADDP.SSS ZIA I PHON-S .B1da pp_2011.doc revised 06121111 STREET ADDRESS ClY, STA=r.,ZiP � I r•AX CO1viACT NA:✓E I P oI L u 4z I STREET ADDRESS CITY, STAT_, ZIP I FAX T7OB u2 �. OWnM-3UILDER 13OwNrRACENT Co?. RKCiOR ❑ CO?`7 U CTORAGEN7 13ARCIirsCT ❑ .`hGL\-R 11 DEVELOPER 13 il�khT tr 6b I LICTSP TYr� a I BLAS. LiC r COIv i PJ Ci 0=2) AIS I ? ICENSB \U 16ER Rill ✓PANYl,k��'-- I E-WAJL FAX COl5 to > a cus.$w ®.-• FAX fte* Sm.T � CdH rt�-G9H 510, 3st.- STATE, ZIP P iOI�t !a't5 C .4 CYYI77 SJ+�:3SJ. ;zest ST=2EET ADDRESS 5-11 ARCH:ITECTrN0NE RNAj11B QQ r I LIC_NSENJA ER 18I S.LICm /CN �s2dH� SBTH _-. S•�'J.f`a�*S7�eNeTio►xrt ,4�Ysl�ka.to.►• C.OIv',PAIVY X.A_*m L - - M Ty, thX X11 D I CTI Y. STATEL. ZIP p nor E STP27rT k.DDPWSS 11!5 fG N L ®si(/a C .A q r 1r 7' % 31./. 7&-e 3 DESCRIPTICNTOrWORK Sn"JMe4AA ✓•DAQGfttel'j �1✓., �d�t I � , E:aS.n G USE PROPOSED USE _UNSTIZ TYPE I € STORIES USE WP= Occ. I SQ.FT. I VALUATION l (s) SE E?y�TG i Lar FLOOR DEMO �/1ne $rwt tAE/6-09� AI TOT Ai - ARA tI ° 16 BATHROOM Ix=C iT-N REMODEL AR 4,�1— PE?.50DEL e I P�I�ODEL.i°EA f, fj� �!.g'� DETACH PORCH AREA DECK I TOTAL DE�C.•i AREA I G ZAC.. hR h: E] ATTACH I I I I I • -c , .' , IS ASECOND UNIT ❑ Y SECOND .TORY ^� O D1 _LLINC J i5:"v BEING ADDED? 17" I � DDITIOA? ISTdEBLDGA'1 ❑T^ s�CI\�D3Y`.:s "` TOT.'.T \�ALiJ.4TION:. IF Y^S, PROVIDE COP Y OP - pp e noyIChTiO @ ❑ \ =S TO PLk','hTldGeaaym MNO PLAT7��SGhPFPOVfT TT': I EICF-LERHOI E'. By my signature belo\,t, I ce; iry to each of the follo na-: I art the property ovmrr or aufh r - ^ ' i e property ou�er's behalf I have ad fh s \ erl)h it -Is amurate: �P o 10 -cal ` yloT th-a i oor°'•I� - he nforn4.ion I hay°e Provided -is co„ecLr l ha\ e re d'the Deserlp.lo� Of"', r. ,and el tpplidabk -Y - application and Cup:.rtlno to enter the cboS e p P P or einances and state laws relating to building construction. I a�_'thoriae represent n Es or _ ._ Date. - Signature of Applicant,/Agert:. - _s OL11rtG �L7� -QL!E SURTM1110? RE .,-mssopjyO"O11:i0.a7t ,i.y d,�eljOII.Eneed".O�gTE;COGtT�'R _ �eW SFDor _fL �, . building(s). De riollt=on pElrllt as requ_ ed prier =o Iss-da,-= of building � - ` `- -�- %��ttP.£3ZVii. ealsting it `te- .. ,_� �� � � � � � -Fit for new bis_.ala, P , B!dE5: PrOV_GIP 8C0 completed mplEted Hazarduus Materials DisclosurE '�i.� 'r�*�e.RI��� ---�-OR _., CO-RiT.Erc1cI berag used PISPartOt u2 5 pi O) ,ct. TOM. HazGTdo l� I\�afc ZIP are 4RG �r LZ LE<i r or?��e ting wi.h?lam nl-2 DT. to � OR Copy ofPlzli?ing Approval � subn,i«sI of Du Pe,, application. .B1da pp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 19620 STEVENS CREEK BLVD DATE: 11130/2015 REVIEWED BY: MELISSA APN: 36906010BP# I EVALUATION: [$o *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION USE:, I -r-- PERMIT TYPE: IGENCOM WORK DA DETAILS FORE RESTROOMS & ELEVATOR SCOPE I 1,fi�ch. Han l'i'l4kh. Ins'v� Fee: -feeh, NOTE. This estimate does not 1, b Lw C&vk Flluwb. llermf� Atsp. fees due to other Departments (ie. Plai Elec,, 1" art I I 11-f7ec, perlo.-,if Fee: 0ther h,'Iec. !;�sln EYzo. layp. Public Works, Fire, - nit Sewer District, School District, etc.. , These fees are based on the Prelimina information available and are only an estimate. Contact the Dept for addnl info. FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 1 # Deferred Submittal $286.001 IDEFSUBM A Suppl. PC Fee: (E) Reg. 0 OT 0.0 hrs $0.00 PME. Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp..Fee.e), Reg. 0 OT 0,0 hrs $0.00 P,Nffi-.Unit,Fee: $0.00 P1;v1E:.Pe'rm it Fee': $0.00 ("OnSiMC17,08 TaX: EJ e Work Without Permit? 0 Yes (D No $0.00 Advanced Planning Fee:'. $0.00: Select a Non -Residential Building or Structure 0 A 1 unienfqqon U -klt 1,fi�ch. Han l'i'l4kh. Ins'v� Fee: -feeh, NOTE. This estimate does not 1, b Lw C&vk Flluwb. llermf� Atsp. fees due to other Departments (ie. Plai Elec,, 1" art I I 11-f7ec, perlo.-,if Fee: 0ther h,'Iec. !;�sln EYzo. layp. Public Works, Fire, - nit Sewer District, School District, etc.. , These fees are based on the Prelimina information available and are only an estimate. Contact the Dept for addnl info. FEE ITEMS (Fee Resolution 11-053 Eff. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 1 # Deferred Submittal $286.001 IDEFSUBM A Suppl. PC Fee: (E) Reg. 0 OT 0.0 hrs $0.00 PME. Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp..Fee.e), Reg. 0 OT 0,0 hrs $0.00 P,Nffi-.Unit,Fee: $0.00 P1;v1E:.Pe'rm it Fee': $0.00 ("OnSiMC17,08 TaX: EJ e Work Without Permit? 0 Yes (D No $0.00 Advanced Planning Fee:'. $0.00: Select a Non -Residential Building or Structure 0 A 1 unienfqqon Strong Motion Fee:, $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 17!7- $0.001 -M. $286.00 $28 6.00 Revised: 10101/2016 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS; 19620 STEVENS CREEK BLVD CONTRACTOR: SMI CONSTRUCTION PERMIT NO: 15110017 INC OWNER'S NAME:EVERSHINE VI, LP 595 MONTAGUE AVE DATE ISSUED: 11/03/2015 OWNER'S PHONE: 4089301275 SAN LEANDRO, CA 94577 PHONE NO: (510)351-3288 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL License Class_. '3 Lic. # d S5 I t b6 MAINFIELD MANAGMENT (STE # 290)- T.I: TO CREATE (l) BREAK ROOM (NO FOOD SERVICE) (165 S.F.) Contractor COrtSj ue Tt v, Yrs Date �r 6,3/r 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: $1500 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: 36906010.00 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 WITIIIlY 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS F LLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, _ costs, andexpenses which may accrue against said City in consequence of th granting of this permit. Additionally, the applicant understands and will cc Date: with all non -point source regulatiots per the Cupertino Municipal Cod , 9.18.' Signatu _ Date %f/O 3Z�5 RE -ROOFS: All roofsinspected 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: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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) 1, 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 Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker', s Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505_25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: d//o31�5 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 CONSTRUCTION LENDING AGENCY 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 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 `and ARCHITECT'S DECLARATION indemnify keep harmless the City of Cupertino against liabilities, judgments, 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 CONSTRUCTION PERMIT APPLICATION COM10UNI T Y DEVELOPA/iEN T DEPARTNAENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CURERTWO (408) 777-3228 •_FAX (408) 777-3333 buildina(ftmer<ino.orct M I I I.MW (-r)VQTDTTr--Tn+.r I7 . 1 -,�-. 1�,......._ .. ----. •-- n -- ( / — -------- u .+....,-..1-a iavaa, a♦ LJ i�:GrLJ1V1V/LLI'LtC1C �'.L VK1lTIPffil,.. j�r,i�j;jT e''r. PROMCf ADDRESS ZAPN R _ Cre+�P.A 5 OWNERNAIYM ' PHONE E-MAIL Jt& (G(iG u) 4i 0-rZ75 STREET ADDRESS Z_IX e1 CPi Y, STATE, Zip' I FAX l q -o S e✓ C�Qe1 I .nu c� '1--5 CON?ACT NAME$ I PHONE I E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX OR 11ER �. OWNER -BUILDER ❑ OWNER AGE -N7 [2"CON`rR4CTOR ❑ CONTRACTOR AGTrr ❑ Aacj TELT ❑ r'Nr, ❑ DE4 �LOPz^i ❑ TLNAhT CONTRACTORNAME r (LTCn'ISENUMBER I LICENSETYPE �,. ( BUS. LIC � c�✓vaI � ��3 91 G6 colvgAw NAME �� Gr�'x�f����': vat. E-MAIL ��,� ��>�j-trbt�i xa i.15Gt� f...�.orv. cam+-• FAX 5 551- IC"!/ (J STREET ADDRESS �✓ 7 P74 -4--L 1,,,.L Ave- CITY, STATt, ZIP PHONE ARCIErECT /ENGINTER NA]✓E LICENSE XMIMER Gq6`i7 .-. BUTS. LIC m COMPANY NAME LL /4'�.>:' da'a�j�fvt '}-j% ... �- I E-MAJL a 7.��� 'I i`-71�61�� Ci 7etatc.c.. F.•, FAX p sfo 3 5 STREET ADDP.ESS CITY, STATE, ZIP �' I PHONE _ jam%' !�'lGon'Fu ew .f}�.e,. ��'tm•a �d/,rn,�ro �.®- ®d ilJr?'7 I DESCRIPi1074 OF WORK l g g ce� �d�Gc- �1'l "� Gt-O��l�` �t'1 `:'li'z,^ y,WPT.I 1�.. G`+�.. d�. 9✓lc't a.' �C la�,� •✓° �„ A Al / Y r -e E71STDdG 1)SE PROPOSED USE/ CONSTR_ TYPE ' STOREMS M%� Y Cl ! t'�Fh/�/' 3 I 6 UsE I TYPE. I OCC. I SQ.FT. VALUATION (S) EXISTG AREA X30®, /' I T� NEV V FLOOR. AREA®� DEMO. I AREA TOTAL I NEI AREA Iii BATIMOOM =CHE_?q OTHER REId70DEL AREA REMODEL AREA RMWDEL. AREA 1 PORCH AREA DECK AREA TOTALDECK/POP.CH?.RSA GARAGEAR?:A: LJDETACH I ❑ ATTACH 9 DIWELLING UNTUS: ISASEC'ONDUNIT ❑YES SECOND STORYn1 YES BEING ADDED? �0 ADDITION? .10 PP.E AYPLICATTON ❑ YES. IF YES, PROVIDE COPY OF I PLA*.TNING:4PPLR 2190 PLANhM\GAPPROVAL LETIT::R IS THE BLDG AN ❑ Y- EICHLERHOME' - - � - j - . -;- :. -;" .,-- TOTAL VALUATIO d �1 G By my signature below, I certify to each of the following: I am the propel owner or authorize agent to ac n t � owner's behalf. I have read this application and the i iformation I have provided is correct. I have rend the Description ofWork and l erii i curate. I agree osirlgl writh ali applicable local ordinances and state lays relating to building construeo i. I authorize representatives -of Cupertino t ter the above-identi Ted proper y for >ction purposes. SignatureofApplicant/Agent: Date: 3 _ s SUPPLEMIrNTA. �i 1TION REQUIREDcsL New SFD or Multifamily dwellings: Apply ror demolition permit for '�� fl�OG�R—THE COL�tTER g 40-1 BUIIDL�GPLNRE}7E� existing building s). Demolition permit is required prior to issuance of bl ilaing for new building. z � � _ � permit ��ss� ��� Commercial Bldgs: Provide a completed Hazardous Materials Disclosure P _ To if any Hazardous Materials are being used as part of this project. u -- Copy of Planning Approval Letter or Meet Piz with Plan*iing prior to o submittal of Buildin-gPermit application._ ex Bldg 4pp_2011. do revised 06121111 CITY OF CUPERTINO � M-0, FEE ESTIMATOR — RTTTT .nT1Vf! nTVTCTn1V �F��:.§�- __ � 'rv� C �✓ 'i E _ i� 'p • .r^ _: 5'.' '' `/ $ y �^` � [ADDRESS: 19620 STEVENS CREEK BLVD DATE: 11/03/2015 REVIEWED BY: MELISSA !V ch. i'/ r (',"h e;f N.-Iijnb. 111cw:. z'c':: APN: 369 06 012 BP#: *VALUATION: 1$1,500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement USEMARY Commercial Building .Alkc,/lray. 1'e ;: 3ifiliti. it j� 1 Fri!: PENTAMATION $0.00 PERMIT TYPE: 1 GENCOM WORK MAINFIELD MANAGMENT STE #,290)- T.I. TO CREATE N BREAK ROOMNO FOOD SERVICE SCOPE (165 S.F.) �F��:.§�- __ � 'rv� C �✓ 'i E _ i� 'p • .r^ _: 5'.' '' `/ $ y �^` � may, ✓ F'�, a',A+��e.� i4� e'W�. i'CA€:s.�h'' �$ "�».'. Eei°k�S.w.3� -s", ^ M - 4 d'a Y f ,� ...� .. „4 ..< k 3,`.�. � ..� e e�_. _s �'f t K. dte' ' z _ r-�'=" S� ' !V ch. i'/ r (',"h e;f N.-Iijnb. 111cw:. z'c':: L..._... €'lfiFt L;.,F ii:i f'LA1. .P.'.'LZZfW.- f Pg:}^## F .jr.'3"Fic Suppl. PC Fee: Reg. 0 OT0.0 t�<:Z_,r lnso7 Other .Alkc,/lray. 1'e ;: 3ifiliti. it j� 1 Fri!: /fJC _ . F=-sp. i ezo: 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 based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-1153 Elf'.' 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes E3 No $0.00 2 hours $286.00 Plan Check, Hourly ISTPLNCK Suppl. PC Fee: Reg. 0 OT0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? Yes No $0.00 Suppl. Tnsp. Fee -e) Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00' PNffiPermit Fee- : $0.00 (£.S .�ifst s/fc,fion .��Lx 0 Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: $0,00 Select a Non -Residential Building or Structure 0 1 rrav el .D()L;7fmentation Fees: Strong Motion Fee: IBSEISMICO $0.50 2.0 hrs $286.00 Inspections ISTINSP Inspection, Hourly Bldg Stds Commission Fee: 1BCBSC $1.00 ,�min UBTQ3 $1.501 $572.00 ' AL E $573.50 Revised: 10/01/2015