B-2016-1623 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1623
10805 N WOLFE RD STE 106 CUPERTINO,CA 95014(316 05 056) LIN'S AIR CONDITION
1NC
i
OWNER'S NAME: CUPERTINO VILLAGE LP DATE ISSUED:05/16/2016
OWNER'S PHONE:415-298-8875 PHONE NO:626-712-3928
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class c22Q Lic.#981177
Contractor LIN'S AIR CONDITION INC Date 2/28/2017 X BLDG —ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
LE QUEENA-T.I. 810 SQ FT ADD(1)PARTITION WALL,
I hereby affirm under penalty of perjury one of the following two declarations: (N)RESTROOM AND(N)FITTING ROOM
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 REV#1 -SWAP LOCATIONS OF FITTING ROOM AND RESTROOM.
performance of the work for which this permit is issued. ISSUED 6/8/16
I have and will maintain Worker's Compensation Insurance,;as provided for by REV#2-NEW HVAC SYSTEM AT ROOFTOP.ISSUED 6/21/16
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$15000.00
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 AFN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 05 056 A(Tenant Improvements),B(Tenant Improvements)
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 PERMIT EXPIRES IF WORK IS,NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municip ode,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 6.1 L1 1� Issued by:Abby Ayende
Date:05/16/2016
OWNER-BUILDER 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
r. 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 for inspection.
sale(Sec.7044,Business&Professions Code)
2. 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 threeideclarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the 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
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9. nd
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Section y2550 and�25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner �/h
rized agent:
APPLICANT CERTIFICATION Date-I certify that I have read this application and state that the above'!nformation is VCONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I her y aat thris a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of w rk's h 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 Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date Professional
CONSTRUCTION PERMIT APPLICATION OnEft
COMMUNITY DEVELOPME T DEPARTMENT•BUILDING DIVISIONa �
10300 TORRE AVENUE^CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•buildingC@-cupertino.org
CUPERTIN4
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALT RAT/ION/TI R VISIO /DEFERRED ORIGINAL PERMIT# -'-016 J 6 Z3
PROJECT ADDRESS r. Q wo( � m t w I O/ APN#
OWNER NAME t ) 4L � !'{J PHONE J ^ .5 E-MAIL
4-xndl,cnI ina)/.W✓' 1
STREET ADDRESS 2s2� Home ��_ry�T r�_I CITY, STATE,ZI �� �?q D�^' FAX
CONTACT NAME l J c`�pt )C•G PHONE �(� E-MAIL) a n�
STREET ADDRESS a-W d ome sl em P d CITY,STATE,ZI I j o, FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CON CTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME I Lin
;n L CENSE NUMBER LICENSE TYPE C2 0 BUS.LIC#
COMPANY NAME II ��/ f '(_C E-MAIL FAX
STREET ADDRESS j n� ,tl� _J•f CITY,STATE,ZIP <DkA r 91 PHONE 6 2 112 3 Y 2 ry
ARCHITECT/ENGINEER NAME �h('_C�,/` Vt���r, L�CENSE NUMBER l 7� / BUS.LIC#
03
COMPANY NAME J' L(�I^(JC(. +/�� /V�l E-MAIL �•G 1 � / FAX
P,Inc
STREET ADDRESy , p ( CITY,STATE,ZIP n - (1� PHONE ^�/92a'/
DESCRIPTION OF WORK. V 1�lr N V 14� /j r P !zoo70,E /q C-6 HA>�YVCi
EXISTING USE PROPOSED USE CONSTR.TYP #STORIES
,,.,•J `1 USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODELAREA REMODELAREA REMODEL AREA
J PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARA E AREA: ❑DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY []YES
BEING ADDED? ❑NO ADDITION? ❑NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE B�DG AN ❑YESRE IVSD Y TOTAL VON:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLE J HOME? E]N0
By my signature below,I certify to each of the following: I am the property owner or auth _ a ent to ac on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Wor n verify` is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building cons ' I authorize representatives of Cupe nter the above red property for inspection purposes.
Signature of Applicant/Agent: Date: 2
SUPPLEMENTAL INFORMATION REQUl1�ED PiAN;CIiECKTYPE; iibtrriNC SLIP, „
New SED or Multifamily dwellings: Apply for demoliti n permit for
-- ❑ OVER THE COUNTER ❑ BUILDING PLAN RE\'iE�y
existing building(s). Demolition permit is required prior to i strance of building
permit for new building. ❑ EXPRESS ❑9 ,PLANNING PLANREYiEW
_Commercial Bldgs: Provide a completed Hazardous Ma erials Disclosure ❑ sTANDaRD ❑ PusLIC woRxs
form if any Hazardous Materials are being used as part of thi project.
❑ LARGE ❑ FIRE DEPT'S
_Copy of Planning Approval Letter or Meeting with Planrl ing prior to
submittal of Building Permit application. -� 1VIAJOR ❑ SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH'
BldgApp_2011.doc revised 06/21/11
t,
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: JII CONTRACTOR: PERMIT NO:B-2016-1623
10805 N WOLFE RD STE 106 CUPERTINO,CA 95014(316 05 056) INNOVATIVE
CONSTRUCTION
IMPLEMENT&
DESIGN CO
SAN FRANCISCO,CA
94121
OWNER'S NAME: CUPERTINO VILLAGE LP DATE ISSUED:05/16/2016
OWNER'S PHONE: PHONE NO:(415)699-4379
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#977270
Contractor INNOVATIVE CONSTRUCTION IMPLEMENT&DESIGN CO Date X BLDG —ELECT _PLUMB
09/30/2016 _MECH_RESIDENTIAL X COMMERCIAL
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 JOB DESCRIPTION:
license is in full force and effect. LE QUEENA-T.I. 810 SQ FT ADD(1)PARTITION WALL,
(N)RESTROOM AND(N)FITTING ROOM
I hereby affirm under penalty of perjury one of the following two declarations:
r. 1 have and will maintain a certificate of consent to self-insure for Worker's REV#I -SWAP LOCATIONS OF FITTING ROOM AND RESTROOM.
Compensation,as provided for by Section 3700 of the Lablor Code,for the ISSUED 6/8/16.
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
Sq.Ft Floor Area: Valuation:$15000.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: Occupancy Type:
information is correct.I agree to comply with all city and county*dinances 316 05 056 A(Tenant Improvements),B(Tenant Improvements)
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 indem ' and keep harmless the PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgment ,cos s,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in conseque a of t e granting oflthis permit.
Additionally,the applicant understands d will mply with all non-point 180 DAYS FROM LAST CALLED INSPECTION.
source regulations per the Cupertino nicip Code,Section 9 I.18.
Issued by:SEAN HATCH l
Signature Date 6 8,16 Date:05/16/2016
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1. I,as owner of the property,or my employees with wages as their sole inspection.
compensation,will do the work,and the structure is not in{ended or offered for
sale(Sec.7044,Business&Professions Code) f Signature of Applicant:
i. I,as owner of the property,am exclusively contracting with licensed Date:61/1E
contractors to construct the project(Scc.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
z. I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will
Section 3700 of the Labor Code,for the performance of thle work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. I Health&Safety Code,Section 25532(a)should I store or handle hazardous
s. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Ma a ent District I
shall not employ any person in any manner so as to become subject to the will maintain compliance with the Cupertino Municipal e, apter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 25505, 33, 25534.
exemption,I become subject to the Worker's Compensation provisions of the
Labor Code,I must forthwith comply with such provision)or this permit shall Owner or authorized agent:
be deemed revoked. Date:6/8/16
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino again st liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1623
10805 N WOLFE RD STE 106 CUPERTINO,CA 95014(316 05 056) INNOVATIVE
CONSTRUCTION
IMPLEMENT&
DESIGN CO
SAN FRANCISCO,CA
94121
OWNER'S NAME: CUPERTINO VILLAGE LP DATE ISSUED:05/16/2016
OWNER'S PHONE:415-298-8875 PHONE NO:(415)699-4379
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic.#977270
Contractor INNOVATIVE CONSTRUCTION IMPLEMENT&DESIGN CO Date X BLDG —ELECT —PLUMB
09/30/2016 _MECH_RESIDENTIAL X COMMERCIAL
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 JOB DESCRIPTION:
license is in full force and effect. LE QUEENA-T.I. 810 SQ FT ADD(1)PARTITION WALL,
(l)RESTROOM AND(N)FITTING ROOM
I hereby affirm under penalty of perjury one of the following two declarations:
i. 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
l/L Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$15000.00
permit is issued.
APPLICANT CERTIFICATION APN
I certify that I have read this application and state that the above Number: Occupancy Type:
316
information is correct.I agree to comply with all city and county ordinances 316 OS 056 A(Tenant Improvements),B(Tenant Improvements)
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 PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments, and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequent of a granting of this permit.
Additionally,the applicant understands agd wil. omply with all non-point 180 DAYS FROM LAST CALLED INSPECTION.
source regulations per the Cupertino rfnic' I Code,Section 9.18.
Issued by:Abby A,en de
Signature - Date 5/16/2016 Date:05/16/2016
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
i. I,as owner of the property,or my employees with wages as their sole inspection.
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with licensed Date:5/16/2016
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
z. I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and25534. I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(a)should I store or hon a hazardous
3. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equipment or devices w emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality agement District I
will maintain compliance with the Cupertino Municip e,Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 2 ,and 25534.
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 Owner or authorized agent:
be deemed revoked. Date:511612016
APPLICANT CERTIFICATION CONSTRU T N LENDINGAGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT'BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building(ftupertino.org -2+�11�-�W��
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECTADDRESS 0 w APNH '?)i(_,oS.O
OWNERNAME m i7 v PHONE +0 VJ E-MAIL
a
STREET ADDRESS N O w` 01 � ITY,STATE,ZIP FAX
CONTACT NAME V k _ • (yam a,lw f� V PHONE E-h1AIL�
�y �iJ`+f1V v+} 1 1 a
cow
STREET ADDRESS r CITY.STAT ZI' F
❑OWNER ❑OWNER-BUILDER 17 OWNER AGENT ❑CONTRACTOR ❑CONTRACTOR AGENT ❑ ARcun'uc'r ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRAC`rORNAME LICENSENUMBER LICENSE TYPE BUS.LICA
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PRONE
ARCUrl' rIENGINHHRNAME LICENSE NUMBER BUS.LICA
COMPANY NAME pLj 1 s M/ E-MAIL m e ` cow
STREETADDRESS L %i (V^V CITY,STATE,ZIP PI'ONE
�Ih�l-CL,f{ieG/Ld ,
Wjpffmm
DESCRIPTION OFWORK M9: 11100 W*d 0) h014---44,
EXISrINGUSE PROPOSED USE CONSTR.TYPE #STORIES
!f USE TYPE OCC. SQ.Fr. VALUATION($)
Emoru �tU!W FLOOR DrAlo TOTAL n ,/��
AREA AREA AREA _ NET AREA el t✓ �1 G, 1h
EATHROO KITCHEN O'IIJER ♦ Vf
REMODEL AREA REMODEL AREA R11MODELARBA
PORCITAREA I DECKAREA TOTALDECK/PORCA AREA GARAGRARHA: D11l1 II
ATTACK
B DWELLING UNITS: IS ASECOND UNIT ❑�Y Bs SECOND STORY DYES
DEDVCADDED? W. ADmrrION? NO
PRF,APPLICAnON []YES jr YES,PROVIDE COPY OF ISTHEDLDGAN ❑YES I'R GIV.I:,A,JIY;','�:;;'+' ��i;.-.fit;�>i�: =:� TOTAL VALUATION:
PLANNINGAPPL# 7NO PLANNING APPROVAL LETTER P.ICOLCR1101110 ❑'NO
By my signature below,I certify to each of the following: 1 am the properly owner or authorized tigcntth act on Ito property owner's behalf. I ave nail Ibis
application and the information I have provided is correct: I have read the Description of Work and verify it is accurate. l agree to comply with all applicable local
ordinances and stale laws relating to building constniction. I autho'' invesentatives ofC to enter the above-identiftetl properly for igspeclion purposes.
Signature ofApplieant/Agent: DRte:
SUPPLEMENTAL INFORMATION ItEQUIRED q��H ciiech rYeE':i:; 'R9tiT11csGtr.,`..:''
New SFD or Multifamily dwellings: Apply for demolition permit ror 'x'`''r"':r`; ii, `' " '1"•-' 1''
'.�1 OVEA TII�COUN'I'CR II tLblivjt'tutry tiFl thW AYY!1
existing building(s). Demolition permit is required prior to issuance of building ti
porrait ror new building. G:eJ.IR S.s.. y, :. El ly ll(C.(LtP(.kSYJEw
_Commercial Bid s: Provide a completed Hazardous Mah;rials Disclosure y'E�:sr``'nA•b::::.•:!+';::.•:r:•->x .�:�i?rli''iie''':b"'""J%''".��`'���'�".'�''�`'
g P dN R
form if any Hazardous Materials are being used as pari of this project. 1
Copy of Planning Approval Letter or Meeting with Planning prior to '`''1" >ti:e...,_:,,r;.:•.:.
.,0?`l4Ll'JOICi: -'`t' =e'rr```. T,ARX,'O ))'EA,DI9TRIC,T.
submittal of Building Permit application. :,; ,,,; .t*,,-`,S`•::`�;y: '?�,:;;i
x•.i�': �~i^,i"� r'i�:rE1+iV1�UNa1li''t�:1L Tt6AGT11)�.
R
Ulc/gApp_2U11.doe.rev is'ed-06/21/11
1
UTILITY RELEASE REQUEST FORM.
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
ALBERT SALVADOR,P.E.,O.B.O.,BUILDING OFFICIAL
liPERTINO 10300 TORRE AVENUE-CUPERTINO,CA 9W14-3255
'C
(408)777-3228-FAX(408)777-3333-buildingAcupertino.oc
PURPOSE
For residential single family or duplex construction,there are cases where gas and electric utilities are
requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the
building inspector,the City of Cupertino is allowing both utilities to be released prior to the final sign-off of
the building.
INSTRUCTIONS
1. Download tl-Iis fore at: httl2://www-,cupertiiio.orL)r/I index.aspx?"age=297.
2. Complete the form and obtain signatures from both the owner of the property and the primary contractor.
3. Fax,E-Mail, Mail or hand deliver the original signed form to:
City of Cupertino
Building Division
Attn: Utility,Release Request Form 408-777-3228 office
,10300 Torre Ave. 408-777-3333 fax
Cupertino,CA 95014 building@cmpert ino.or
4. Schedule a Gas Meter Release inspection(4403)and/or Electric Meter Release inspection(#404), Please
note, a Gas Test inspection(fiS06)is required prior to or at the same time of the Gas Meter Release
inspection,
BUILDING INFORMATION (Please complete the following information):
APN -7E3.LDG PERMIT DAT :
I E 4-4-16
SITE
10805 N WOLFE kD #106 CUPE,RTINO C.A. 95014
ADDRESS-
OWNER'S NAME: PHONE*
X1A0VH LUFAX#.
MAILING ADDRESS(if different from site address): 2528 _l-Wj
Ar=,S-1=AjD 2D, SANTA C-LARA CA 01505 t .
CON I TRACTOR: CANLIAN FANG PHONY#: 9 0 9 .5 6 9.2 0 a-9
FAX#.
CONTACT- KEN FANG PHONE#: , 909.569_2 69
FAX* 626 .,608 .0445
I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of
the building cannot move into the residence f,until they receive all of required final siqri>offs and the City has issued a certificate of
occupancy for the buildinq
Owner;...... .................... ............... .....Print:..... ...... .......
Contractor:.. ........ ...... Print:......-CANLIAN....FANG-... .........
t1n1i0)I?e1ea&&Forat_.20J Ld6c revised 081098 1
Ek
�{
F1
CAPEACENGINEERING INC
PO BOX 11198.1 RlrMONT,CA 94519
Tel (510) 68-1 1"l uv(5W)490.86
June 29,2016
PrQject o. 10761
Building Department
City of Cupertino
10300 Torre Ave.
Cupertino, CA 95014
Subject: T.1 for Le Queeriat
1.0805 N, Wolfe R .s Sty;, 1116
Cupertino, C
( ' mit No.B2016-1623)
SPECIAL INSPECTION SERVICES FINAL AFFIDAVIT FOR
` EL WELDING
Dear Sir;
APEX ENGINE,MING INC., has provided testing an special inspection, services
the subject site in accordance witl section 1704A,ofthe aliliorn.i uildin Carle 11
Edition) s listedbelow:
Visually inspected fillet -welds on add L 4x 4 x 'X," steel angle to existingste,,l
deckingusing FCAW procesNdthR 232 Noire by one certified welder t air`
duct opening each side.
Personnel and r the gerleralsupervision of aregistered,Civil Engineer performed these
inspections. Based on the irspe ti ns perfornied.andupon our tanti t reports that
the inspected work was p ri' rr re ,to the fest of our knowledge,:in conformance with tl
approved plans arra specifications and the applicable"v rkr tarrslrip provisions of the
California 1pnil in '- al t
y,
rrrcrl=x
Gary Asif�p,l
,/Vzo)
Principal
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