15090075 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20803•STEVENS CREEK BLVD CONTRACTOR:SILICON X PERMIT NO: 15090075
CONSTRUCTION INC
OWNER'S NAME: SA1CH WAY STATION LLC 2051 JUNCTION AVE DATE ISSUED: 10/28/2015
OWNER'S PHONE: 4084534700 SAN JOSE,CA 95131 PHONE NO:(408)418-0099
LICENSED CONTRACTOR'S DECLARATION : JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
T-MOBILE-STE#105-T.I.TO BUILD OUT SHELL TO
License Class Lic.# �j �—� (N)M OCCUPANCY(1,667 S.F.)
Contractor t 1 i c ak-;-X Cgg-r_ Date IV ''-99
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:$160000
t. 1 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 APN Number:32632042.00 Occupancy Type:
o ce of the work for which this permit is issued.
e and will maintain Worker's Compensation Insurance,as provided for by
ection 3700 of the Labor Code,for the performance of the work for which this
permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICA'T'ION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 certify that I have read this application and state that the above information is 180 DAY AST CALLED INSPECTION.
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 y: Date: ( /
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 no urc regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS:
FAII scall be inspected prior to any roofing material being installed. If a roof is
Signature Date 10'� installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OW ER-B ILDER DECLARATION Signature of Applicant: Date:
T 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:
t. 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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code) 1 have read the hazardous materials requirements under Chapter 6.95 of the
2. 1,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should l store or handle hazardous material.
T hereby affirm under penalty of perjury one of the following three declarations: Additionally,should 1 use equipment or devices which emit hazardous air
t. I have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by w r or authorized agent:
Section 3700 of the Labor Code,for the performance of the work for which this Date: E
permit is issued.
3. I certify that in the performance of the work for which this permit is issued,l shall CONSTRUCTION LENDING AGENCY
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 I hereby aothbn
mthere isa construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for which it is issued(Sec.3097,Civ C.)
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
revoked. Lender's Address
APPLICANT CERTIFICATION ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is I understand my plans shall be used as public records.
correct. 1 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 Licensed Professional
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
COMMUNITY DEVELOPMENT DEPARTMENT^BUILDING DIVISION ` s
A °CIS 10300 TORRE AVENUE^CUPERTINO, CA 95014-3255
GU�'L��t, 9mo (408)777-3228^ FAX(408)777-3333^building
taacupertino.org J 50170 a 7-5
❑NEW CONSTRUCTION ❑ ADDITION ® ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 20803 Stevens Creek Blvd., Suite 105 APN# 326-32-042
OWNERNAME Saich Way Station LLC PHONE (408)453-4700 E-MAIL larry@borelli.com
STREET ADDRESS 2051 Junction Ave., Suite 100 CITY, STATE,zIP San Jose, CA 95131 FAX (408)453-5636
CONTACT NAME Robert Bearden PHONE(925)678.2033 E-MAIL bob@fcgainc.com
STREET ADDRESS 301 Hartz Ave., Suite 213 CITY,STATE,zip Danville, CA 94526 FAX (925)820-5858
El OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR El CONTRACTOR AGENT NI ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME Tony Gonzalez LICENSE NUMBER 983292 LICENSE TYPE B BUS.LIC#
COMPANY NAME SiliconX Construction E-MAIL tony@siliconxconstruction.com FAX (408)453-5636
STREET ADDRESS 2051 Junction Ave., Suite 100 CrrY,STATE,zIP San Jose, CA 95131 PHONE (408)418-0099
ARCHITECT/ENGINEERNAME Cedric Craig LICENSENUMBER C-15490 BUS.LIC#
cOMPANYNAME FCGA architecture E-MAIL ric@fcgainc.com FAX (925)820-5858
STREET ADDRESS 301 Hartz Ave., Suite 213 CITY,STATE,zIP Danville, CA 94526 PHONE (925) 820-7585
DESCRIPTION OF WORK
Tenant improvement to include interior partitions with painted gypsum board finish,finished ceilings,
flooring, lighting and electrical outlets, HVAC system, one restroom, utility sink, kitchenette cabinet
with sink and new window film at clerestory lass.
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
Mercantile Mercantile V-B 1 USE TYPE OCC. SQ FT VALUATION($)
EXISTG 1667 NEW FLOOR DEMO TOTAL Mobile
AREA AREA 0 AREA 0 NET AREA 1667 Mercantile V-13Phone 1667 $160,000
Sales
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
[]ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
0 BEING ADDED? NO ADDITION? ®NO
PRE-APPLICATION IM YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YW#V '- TOTAL VALUATION:
PLANNING APPL# E]NO PLANNING APPROVAL LETTER EICHLER HOME? " $160,000
By my signature below,1 certify to each of the following: 1 am the property owner or autho ei c agent to act o e prop owner's behalf. 1 have read this
application and the information I have provi ed is correct. 1 hav read the Description of Work and verify' acc I agree to comply with all applicable local
ordinances and state laws relating to it tr ction. r' a epresentatives of Cupertino to e a ove-identified property for inspection purposes.
.111
Signature of Applicant/Agem Date: 09.11,2015
SUPPL ENTAL INFORMATION QUIREDPLAN CxECKTYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for ] ovER-THicouiuTER ,�_' D sUu Dnvc Pinxuav�W
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EZPI EsS, ❑'ILANNiNG PLAN REVIEW "
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS` R
form if any Hazardous Materials are being used as part of this project. ❑ LARGE �❑ FIRE DEBT u
_Copy of Planning Approval Letter or Meeting with Planning prior to m
❑, MAJOR •• ❑„SANITARYSEWER DISTRICT
submittal of Building Permit application.
❑ -ENVIRONMENTAL HEALTH
BldgApp_2011.doe revised 06/21/11
F 3�W=Wlw� CITY OF cCUP ERTINO
FEE IESTEMATOR—BUILDING DIVISION
ADDRESS: 208$03 SIFEVENS CREEK BLVD (DATE: 09/1112015 REVIEWED BY: MELISSA
APN: 326 32 042 BP#: *VALUATION: 1$160,000
*PERMff TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION 1M TI
USE: I I PERMIT TYPE:
WORK T-MOBILE- STE# 105 -T.I. TO BUILD OUT SHELL TON M OCCUPANCY (1,667 S.F.
SCOPE
OCCUPANCY TYPE: TYPE OF 1FLR AREA PC FEES PC FEE IID EP FEES BP FEE ID
CONSTR. s.4
M (Tenant Improvements) II-B,III-B,IV,V-B 1,667 $3,004.68 IMTIPLNCK $1,532.96 IMTIINSP
TO'T'ALS: 1,667 $3,004.68 $1,532.96
I
M,EcCH 0� Yes
i ,HOURLY 0 No PLUMB,HOURLY 0 Yes Q No ELEC,HOURLY C) Yes (E)No
.i/ech. Plaut Check I'htnah. Plan Check f lee.. Plan Cheek
illeeh. Permit Hee: Plumb.Perwit Fee: Rec.Permit Fee:
Other,Vech. hasp. L Other Pluntb Insp, E I Olher l;lec. Insp.
ilech. hap. Fee Phamb. Insp, Fee: Elea Insp, Fee:
NOTE: This estimate does not include fees due to other(Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer(District,School
District,etc. . These ees are based on the prelimina information available and are on! an estimate. Contact the Det Lor addn I info.
(FEE ITEMS(Fee Resolution 11-053 Eff. 711113,) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $3,004.68 Select a Misc Bldg/Structure
Suppl.PC Fee: (E) Reg. C) OT 0.0 has $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $1,532.96
Suppl. Insp. Fee:(D Reg. 0 OT 0,0 has $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Con.siruclion Tux:
r1Clnnnistrative Fee: 0
Work Without Permit? C) Yes 0 No $0.00 E)
Advanced Plannin&Fee: $0.00 Select a Non-Residential 0
Travel Documentuiion Fees: Building or Structure 0
Strong Motion Fee: IBSEISMICO $44.80 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $7.00 L�l
I SUBTOTALS: $4,589.44 L $0.00 TOTAL FEE: $4,589.44
Revised: 07/02/2015
f Building(Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
I Telephone: 408-777-3228
Fax:408-777-3333
CONTRACTOR SUBCONTRACTOR LIST
JOB ADDRESS: 2 Q 2��Ie5t,
IS e IT#OWNER'S NAME: k Vor, L L PHONE# ('g 51 -
GENERAL CONTRACTOR: vj /we�r`O BUSINESS LICENSE# 3
ADDRESS: 20-5) —) L:VtC �0v1 ,i 0 CITY/ZIPCODE: �
*Our municipal code requires all (businesses working in the city to have a Cagy of Cupertino business license.
NO BUILDING FINAL OR (FINAL OCCUPANCY INSIPIEC' RON(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUIPlE1RTINO
BUSINESS LICENSE.
I ani not using any subcontractors:
Signature Date
please check appflcaible subcontractors and complete the following information:
V SUBCONTRACTUR II$USE MESS NAME BUSEN ESS UCIEI\NSIE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting -�.�,• �C v"e
Linoleum/Wood
Glass/Glazing
Heating
Insulation CA
Landscaping
Lathing
Masonry
Painting/Wallpaper 4- j r
Paving
Plastering
Plumbing er
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature (Date
TEMPORARY CERTIFICATE OF OCCUPANCY FORM
COMMUNITY DEVELOPMENT DEPARTMENT^BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL Tt
10300 TORRE AVENUE^CUPERTINO,CA 95014-3255
CC I PERTIN® 1 (408)777-3228 o FAX(408)777-3333 <build inq(Dcuoertino.orq
APN ,�11 BP#' DATE:r PROJECT
3 - 3,;--oqa 150 rl Ud-'S 01104 04 120(b VALUATION: � l b Din
SITE 20%03 Gtf-VenS �.6C'G bbJ4 Pa^11ho cA Q561�
ADDRESS:
OWRER'S NAME: PHONE#: '109-463-4700
S 011 Gh W $ `Do i'LC. FAX#:
MAILING ADD,:, SS if different from site address):
2051 u r c 0 ti hie., 100 San jog- LXt q5 I c3
CONTRACTOR: PHONE#: q0'3- 53-4700
siliur\ XYstmiilchDYE- FAX#: 408. 453- b
CONTACT: PHONE#: 409- 31- 196111
FAX#:
TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION
BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION c 00 [BLDBONDS] CODE
CHECK ❑ CASH BOND 1OFBOND: 5K min-10K max u EDITION:
TCO EXPIRATION _
,Z- -lam, EE: $286.00/m0 TOTAL FEE: $ � (�� [1TEMPOCC]
DATE(6 MONTHS MAX). , -
USE TYPE OF FLOOR OCC LEVEL COMMENT
CONSTR AREA LOAD
OTHER DEPART4VIENT/AGENCY APPROVALS:
Ianatur - - - b--APPROVED ❑ APPROVED WITH CONDITIONS`
Signature:............ ,:_. .�.� Date:....,�c........ r.:,,.
ire
Signature:..... .. ................................. Date:...."g�.�..C� APPROVED ❑ APPROVED WITH CONDITIONS'
u is o s
Signature:.........................................................Date:...................... APPROVED ❑ APPROVED WITH CONDITIONS'
Other:
Signature:..... ...........I......I................................Date:...................... ❑ APPROVED ❑ APPROVED WITH CONDITIONS`
`CONDITIONS OF COMPLETION -Attach a letter signed by the contractor and owner of the property
stating the list of items required to be completed for each individual Department before final occupancy
can be granted. Include approximate completion dates for each item.
The undersigned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or
buildings complete and in compliance with all building codes,ordinances and regulations and ready for inspection prior to the expiration
date specified. If this Temporary Certificate of Occupancy expires,the total amount of the bond may be forfeited and the non-compliance
may result in an enforcement action. ,
Owner _ � Contractor
,, i � .Si nature:. Si naturec
. . .. ............Date: ......................
This temporary certificate ensures that all fire protection and life safety systems have been c mpleted,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_-
Building Officia� .. : ............. ..... - -----..............Print:.... ..................Date:... ...//..'f-......
DEPARTMENT ACTION: After determination, copies to: 1)applicant, 2)permit file
TempOccForm_2013.doc revised 717114