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14060171CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20803 STEVENS CREEK BLVD CONTRACTOR: SILICON X PERMIT NO: 14060171 CONSTRUCTION INC OWNER'S NAME: SAICH WAY STATION LLC 2051 JUNCTION AVE DATE ISSUED: 11/07/2014 OWNER'S PHONE: 4084534700 SAN JOSE, CA 95131 PHONE NO: (408) 418 -0099 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL VITAMIN SHOPPE T.I. - BUILD OUT SHELL FOR (N) M OCCUPANCY (3500 S.F.) 7'rit '..tor,K},,'t t I hereby affirm that I am licensed wider the provisions o '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 p rformance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $130000 ave 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: 32632042.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION ertify that l have read this application and state that die above information is PERMIT EXPIRES IF WORK IS NOT STARTED (1 correct. I agree to comply with all city and county ordinances and state laws relating WITIIIN 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 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, J costs, and expenses which may accrue against said City in consequence of the Issued b �/�� if� granting of this permit. Additionally, the applicant understands and will comply Y 6 Date: with all non -po' source regulations per the Cupertino Municipal Code, Section 9.18. RE- ROOFS: Sigr`= "� -- = �"� -- = ?'w `• p tee° 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. ❑ 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 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, acid the structure is not intended or offered for sale (See.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 th Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Seen s 25"255 and 25534 y Section 3700 of the Labor Code, for the performance of the work for which this Owner o au hT�L:x` permit is issued. 1 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 must 1 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. l 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, ARCHITECT'S DECLARATION 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 CUPERTINO TEMPORARY CERTIFICATE OF OCCUPANCY COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 - FAX (408) 777 -3333 • build ingCa)cupertino.org FORM Ti APN .p4 BP #: A.0 &0 j`% % DATE: 5 —S7- /S' CHECK ❑CASH BOND PROJECT $ VALUATION: SITE ADDRESS: 02 U S 0 3 TCO EXPIRATION OWNER'S NAME: PHONE #: TOTAL FEE: $ �.� �-- [1TEMPOCC] FAX #: St er: gnature :.......................... ............................... MAILING ADDRESS (if different from site address): 57 */0 " ::F ❑APPROVED CONTRACTO : 5 f c 1� -- e 4C —� PHONE #: FAX #: ^ �� 7 �� 3 'Co NTACT: � PHONE #: FAX #: TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION_ BOND TYPE: ❑ SURETY BON70MFOONTD: U (1 % VALUATION $ �DOO (BLDBONDS] CODE CHECK ❑CASH BOND 5K min- 10Kmax EDITION: TCO EXPIRATION APPROVED WITH CONDITIONS* J FEE: $286.00/m0 TOTAL FEE: $ �.� �-- [1TEMPOCC] DATE (6 MONTHS MAX):e1fi/CfS �PPROVED WITH CONDITIONS* St er: gnature :.......................... ............................... Date:...................... USE TYPE OF CONSTR FLOOR AREA OCC LOAD LEVEL COMMENT ' APPROVED WITH CONDITIONS* u is Works . --" -, Signature:.....,. .. S i Date:.. ........ $-. ❑ APPROVED �PPROVED WITH CONDITIONS* St er: gnature :.......................... ............................... Date:...................... ❑APPROVED ❑APPROVED WITH CONDITIONS* OTHER DEPARTMENT //J(GENCY APPROVALS: annn9 Signature . ........... Date.. .... . ❑ APPROVED APPROVED WITH CONDITIONS* ire � .. Signature ...... . ................. S S/ Date:.......:S ....... ' APPROVED WITH CONDITIONS* u is Works . --" -, Signature:.....,. .. S i Date:.. ........ $-. ❑ APPROVED �PPROVED WITH CONDITIONS* St er: gnature :.......................... ............................... 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 underspned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or buildings c mplete and in compliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration date specifi d. hi a porary Certificate of Occupancy expires, the total amount of the bond may be forfeited and the non - compliance may result i an en rc ment action. Owner ....��.1II ...�.�.. Contractor ..... Signature:. ..--� Date:.Signature:... Date: . /.r/ ..c� '..✓ This temporarertific—aTe—ensures that all fire protection and life safety systems have bebn,E`ompleted, inspected, successfully tested and approved for the specific-a a e building specified above to `provide a reasonable degree of safety to the occupants from fire and similar emer e BuildinO ... ...... .. ... I ....... ........... ......v......... ..... Print:.... �? .. ... /.. ............... .....................Date:..... .... ./. ...... DEPARTWNT ACT r determination, copies to: 1) applicant, 2) permit file �li1Pi /Ss� N Temp0ccForm_2013. doc revised 717114 CUPERTINO CONSTRUc'noiq PERNTAPPUCAMN U`� COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(@cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ICI ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS Zo?o3 ST1 =vws CREEK :3Lv_b sHoP57 APN# 3 2 6 - 32 — 0 2 O WNER NAME C J Cl I I \ �� / ✓ ' --z ak SIRE T ADDRESS / J V�L r ,� U V V CITt� ATE, Z� Z A FAX CONTACT NAME L� PHONE_`J" EMAIL STREET ADDRESS \ V l t(C ` ( v CITY, STATE FAX K-OWNER ❑ OWNER -Bum DER ❑ OWNER AGENT ❑ CONTRACTOR 0 CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CON CTORNIAM G p r // LICEN D1jJI�ER �bl� LICENSE TYPE BUS. LIC # COMPANY NAME E MAIL f i s v FAX STREET ADDRESS ., � � � Q Ve CITY, STATE, ZIP �„ P`4 ®113 6+ ARCHITECT GINEERNAME Y�v� Vv LICENSE NUMBER /� ^ l (Roll BUS. LTC # COMPANY NAME � G � E -MAIL Co"N"Lf -, $ovche FAX y1S °I7y ISSts 1'c J' ecfuy- hbou c 15 e IP MC r - c.tvre:: C61,I., . PHONE 47z/. . D O C)-2- STREET ADDRESe �SO 5 v _� C 5V 1� �O D TA C, h c i 5 G q 0114 I DESCRIPTION OF WORK ' �[ TCh f " ti e V ita M;A 5 k9epe 11 ki e w 41 an ex'St'yt 561 '.Id ov S I .eS 5 A 96trbomS 3acK►'ooM Di5 /a A►'ea1 Cel��h Wi fhassocia J; "'K d�c i�pl/K,Mew ��hi5he5 drs (ay 5 EXISTINGUSE p PROPOSED USE CONSTR. Meycoif 112 lie r'ca1t file TYPE V -3 # STORIES b Al f- USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG AREA NEW FLOOR AREA DEMO AREA N1,J TOTAL NET t " /� 3� ( /ail BATHROOM KITCHEN OTTER REMODELAREA REMODELAREA REMODELAREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA ❑ DETACH I ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY []YES BEING ADDED? ❑ NO ADDITION? ❑ NO PRE - APPLICATION OYES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES IVED AL VALUATION: PLANNING APPL # KNO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO t, 3o O O 0 By my signature below; I certify to each of following: I am the property owner r aut ed o the owner's behalf. I have read this application and the information I have pr ded is correct. the Description o o accurate. I agree to comply with all applicable local ordinances and state laws relating to b ng c repres entativ s -of Cupertino to enter the above - identified pr PC for inspection purposes. P Signature ofApplicanUAgent: Date: SUPPLE MEN N D PLAN CHECK TYPE ROUTING SLIP ❑ ovER- THE COUNTER 0 BUILDING PLAN REVIEW _ New SFD or Mi. if an y for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS El PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS for m if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE 'DEPT V / Copy of Planning Approval Letter or Meeting with Planning prior toL ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. OKA 5 h I 6 4eO Ci G voeGl ❑ ENVIRONMENTAL EMALTH BldgApp_2011.doc revised 06121111 5A6 CUPERTINO & ow 4 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: 26 D 3 re,-�44J !; Cv1� PERMIT # 3 / -2 0 OWNER'S NAME: 54.,a (,� �L� PHONE # -%6,?- 5-1 q - 9 3 Co GENERAL CONTRACTOR: r BUSINESS LICENSE # ADDRESS: O1 os'/ J, ,,_�, CITY /ZIPCODE: S. J` c 17 r-1 *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 V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing - C- D Electrical x/20 D Im Excavation C21 Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing �,, C C., ,.,- s S 3 �o 3 Heating �'itL!- ('x+L -'i, C'X-r-f '�7) S,j & - Insulation �� ( �nJS c�, 5 Landscaping S o Lathing,.1= =� . V/Yasonry Painting /Wallpaper j f VM Paving Plastering Plumbing AS S 6 A5 {5� Roofing - Septic Tank ,Sheet Metal Sheet Rocic�;, Tile Owner / C nt ctor Signature Z ^2-3 -lie Date D ri \ h A Building Deparbk� City Of Cupertino" 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408-777-3228 C U P E RT 1 N O Fax: 408 - 777 -3333 CONTRACTOR / SUBCQNTRACTOR LIST JOB ADDRESS: -20 C) ; 5 S° PERMIT # - 0 6 ®j / BUSINESS NAME OWNER'S NAME: Gc/ 5 PHONE #d-! - �3 Cabinets & Millwork GENERAL CONTRACTOR: 6 L,,, - BUSINESS LICENSE # 3o z 2— ADDRESS: CITY /ZIPCODE: 'I C 13 I *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 t/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing V Electrical p >A 31 g l Excavation Fencing r/ Flooring / Carpeting Linoleum / Wood Glass /Glazing 601/ �l CSI S rV, Heating "I-D1 160�v S' Insulation Landscaping Lathing Masonry t,". Painting / Wallpaper Paving Plastering Plumbing S 6 61 l Roofing Septic Tank Sheet Metal Sheet Rock /,u ,ti 2 Tile v O er Contractor Signature Date �//5 CUPERTINO TEMPORARY CERTIFICATE OF OCCUPANCY FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 * FAX (408) 777 -3333 * buildingna.cupertino.org APN y_6 32 ^ 0+ -p _0 &0 17 f1 DATE: �$ ` is— PROJECT VALUATION: SITE ADDRESS: o2 U e 0 3 �5; EDITION: TCO EXPIRATION jover OWNER'S NAME: 62 PHONE #: FAX #: DATE (6 MONTHS MAX): �,p S .. MAILING ADDRESS (if different from site address): S' v,� arrn� i rfi/ c� a c &"e' CONTRACTO : j f �6 �a� > TY°– sad7�J PHONE #: FAX #: ��7 3 CONTACT: f PHONE #: FAX #: TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION. BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION C (BLDBONDS] $ 7�� CODE CHECK ❑ CASH BOND OF BOND: 5Kmin- 10K max I ` EDITION: TCO EXPIRATION jover FEE: , $?86.00/m0 TOTAL FEE: $ [iTEMPOCC] � DATE (6 MONTHS MAX): �,p S .. – - iPPROVED WITH CONDITIONS* USE TYPE OF CONSTR FLOOR AREA OCC 'LOAD LEVEL COMMENT _ V u is ors . ,..._�._. ture:..... .......... ❑APPROVED iPPROVED WITH CONDITIONS* [4Signature: ..... ..................... ............................... Date:...................... APPROVED APPROVED WITH CONDITIONS* OTHER DERARTMENT &AGENCY APPROVALS: Sigann 3 nature :..... ... Date... ......... ❑APPROVED APPROVED WITH CONDITIONS* ire Signature ::............Zl ................ S S Date: .... ❑ APPROVED APPROVED WITH CONDITIONS* u is ors . ,..._�._. ture:..... .......... Date:S 7 �� ❑APPROVED iPPROVED WITH CONDITIONS* [4Signature: ..... ..................... ............................... 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 undersjned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or buildings c mplete and in compliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration date specifi d. hi a porary Certificate of Occupancy expires, the total amount of the bond may be forfeited and the non - compliance may result i an en rc ment action. Owner I �/ �1 Contractor, Signature:......... ............................ Date:�.....1...�.�ll Signature:......y ............................. Date:...... ..1. This temporary ec rtificafe ensures that all fire protection and life safety systems have been e�ompleted, inspected, successfully tested and approved for the specific- a e building specified above to provide a reasonable degree of safety to the occupants from fire and similar emergeaGi < �' / /I '. / IBuilding�ic��. ..... ............................... Date:........ DEPAR , NT M;T r determination, copies to: 1) applicant, 2) permit file ft� TempOccForm_2013.doc revised 717114 CITY OF CUPERTINO F"-Iff FEE ESTIMATOR - BUILDING DIVISION imADDRESS: 20803 STEVENS CREEK BLVD DATE: 06/26/2014 REVIEWED BY: MELISSA PC FEE ID APN: 326 32 042 BP #: *VALUATION: 1$130,000 *PERMIT TYPE: Building Permit PLAN CHECK TYP : Tenant Improvement PRIMARY USE: Commercial Building $2,867.85 PENTAMATION PERMIT TYPE: 1 M T� WORK VI lkl SHOPPE T.I. - BUILD OUT SHELL FOR N M OCCUPANCY 3500 S.F. SCOPE 0.0 OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID M (Tenant Improvements) II- B,111- B,IV,V -B 3,500 $3,191.15 IMTIPLNCK $2,867.85 IMTIINSP Elec. Insp. Fee: $2,867.85 Suppl. Insp. Fee:Q Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ( "'onsin "Iction Tax: Administrative PIT: 0 0 Work Without Permit? 0 Yes Q No $0.00 TOTALS: 3,500 $3,191.15 Travel Doeumenrxion Fees: $2,867.85 Strong Motion Fee: IBSEISMICO MECH, HOURLY 0 Yes (D No PLUMB, HOURLY 0 Yes Q' No ELEC, HOURLY 0 Yes Q No Mech. Plan C'hec'k pilw1b. flea'! Chr.wA Elec ". I'l<.77'i t'hc'CI( Afech. Petv7ail Fete: llhimb. Permit Fee: is "! c. Perar7ir Fee: Other .-/tech. trap Other Plumb Insp Other LIcc. burp. 14ech. L7sp. 1"e.: Plumb. h7sp. Fee: Elec. 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 fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11 -053 L ,' 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $3,191.15 Select a Mise Bldg /Structure or Element of a Building i Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $2,867.85 Suppl. Insp. Fee:Q Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ( "'onsin "Iction Tax: Administrative PIT: 0 0 Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential 0 Building or Structure 0 i Travel Doeumenrxion Fees: Strong Motion Fee: IBSEISMICO $27.30 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $6.00 SUBTOTALS: $6,092.301 $0.00. " TOTAL FEE: 1 $6,092.30 Revised: 04/01/2014 CUPERI'INO PURPOSE HAZARDOUS MATERIALS CHECKLIST COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 a building(a)cupertino.org FR0 3Ecr : M VIT4Mw5,pf 20 ?03 STEvbvS CKE6r\ B[v .5140 P5 7 To minimize possible delays that would result for the Fire Department plan review, please complete the following checklist to determine if an additional level of Hazardous Materials plan review will be required. MARK `YES' IF THE PROPOSED SCOPE OF WORK INCLUDE ANY OF THE FOLLOWING? PLEASE MARK YOUR ANSWER WITH AN `X' IN THE YES OR NO BOX ON THE SIDE BELOW. YES NO 1. Use, dispensing, mixing or storage of flammable or combustible liquids or gases, hazardous materials, etc. 2. Battery back -up rooms or racks. 3. Propane tanks. 4. Gasoline stations with underground tanks. 5. Installation or replacement above ground or underground storage of liquid petroleum products, liquefied petroleum gases, compressed natural gas, explosives or other regulated hazardous materials. 6. Gas rooms for dentist, doctors or veterinarians. 7. Generators with back -up diesel or other fuels. 8. Large refrigeration systems. 9. fuel cell systems. 10. Commercial pool systems. 11. Chemical Storage areas. 12. Flammable liquid storage. 13. Compressed Gases. 14. Dry cleaners. 15. Print Shops. 16. Auto Repair and Auto Body Shops. 17. Research and Development. For any additional information regarding this checklist, please contact Hazardous Materials Specialist, Santa Clara County Fire Department, at (408) 378 -4010. HasMat 2011.doc revised 03107111 CALGREEN SIGNATURE DECLARATIONS Project Name: the Vitamin Shoppe Project Address: 20803 Stevens Creek Blvd Prpjei:;t Description: 3,500 Sq.Ft. Retail TA. to a new shell building SECTION I DESIGN VERIFICATION! Complete all lines of Section 1 — "`Design Verification" and submit the completed checklist (Column"s 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above :are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as adopted by the City of Cupertino. 02,4 -,- - 1� R (t�, (kq Owner's: Signature Date Owner's Name (cease Print) Desianfflrofesjbnars Signature You g : Wong Desig Qrofessional's Name (Please Print) Signature of License rofessional re/s�ponsriibble for CalGreen compliance Name of License Professional responsible for CalGreen compliance - 0 Email Address for License Professional responsible for CalGreen. compliant e 0811912014 Date IL Date r� /t A AN , SHALL REMAIN o ALL 7-' OrlA r r. MES X i �_ - SECTION 2 - IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2013 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance.(Please Print) Phone Email Address for License Professional responsible for CalGreen compliance Page 9 of 9 CalGreen Non -Res Checklist.doc revised 01123114