15120126R11
G
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20700 STEVENS CREEK BLVD
CONTRACTOR: DUPLAN PERMIT NO: 15120126
CONSTRUCTION INC.
OWNER'S NAME: BYER PROPERTIES LP
390 INDUSTRIAL ST DATE ISSUED: 12/23/2015
OWNER'S PHONE: 4156262937
CAMPBELL, CA 95008 PHONE NO: (408)866-6682
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
�//�� C TK l VL)
kicense
EVER SMILE - T.I. TO RECONFIGURE 1,470 S.F FOR NEW
Class�/ I #
DENTAL OFFICE (M.E.P.'S)
� LLic.
/I
I' ontractor I✓UQJ e S f KkaM'_1 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: $97000
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
APN Number: 3.5908028.20700
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
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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Issued by: Date:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18. /
� (
RE -ROOFS:
Signature Date��
All roofs shall be inspected prior to any roofing material being installed. If 0 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, S i ns 25505, 5533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which thisig
permit is issued.
{, caner or authorized agen Date: 121
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
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
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
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
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 - building aC )cupertino.ora ce—/ Z
CUPERTINO I --1
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS dl + M
002g
I A -Ai - ` P �S 'V �� Z' / ,� E-MAIL C%
STREETA, -+ / 3 4/- �� 1N /1 /J%j�
� ( V V jrL
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �� LICENSE NUMBER LICENSE TYPE BUS. LIC #
COMPANY NAME E_MAIL1 -I - FAX ,•J 1^�. a r , ,.
STREET ADDRESS CITY, STATE, ZIP fl P{IO.NE
trv.,nit��\��C3U�r�i l(7ir�fn
USE
BUS. LIC #
•
TYPE I OCC. SQ.FT. I VALUATION ($)
IS NEW FLOOR DEMO - TO
L
AREA AREA NE O V,4
a 1#16 CH
BRrHMOM KITCHEN OTHER
REMODEL AREA REMODEL' AREA REMODEL AREA
ATTACH
# DWELLING UNITS:
IS A SECOND UNIT E]YES
SECOND STORY LJYES
BEING ADDED? []NO
ADDITION? []NO
PRE -APPLICATION []YES IF YES, PROVIDE COPY OF
PLANNINGAPPL# ❑NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑ YES'
EICHLER HOME? ❑
9 ALUATIO
By my signature below, I certify to each of the following: I am the property owner or authorhe agent t 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 Work and venfy it is accurate. I agree to comply with all applicable local
ordinances and state laws relatinh. b ilding co ction. I ho 'ze representatives of Cupertino to enter the above -identified prope for inspection purposes.
Signature of Applicant/Agent:2a A Date: ,� "/�*'
SUPPLEMENTALORMATION REQUIRED
r%rNcxECK'evPE
RouTI>`G."sLlr., A`
0
❑
New SFD or Multifamily dwel mgs: Apply for demolition permit for
_
existing building(s). Demolition permit is required prior to issuance of building
OVER-THE-COUNTER
`BUILDING PLAN REVIEW
permit for new building.
❑, ExPRiss
❑ <riAN ryPLANREviE�v .�
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑,- STANbA 2D
U1 pUBEWWORKS
form if any Hazardous Materials are being used as part of this project.
EI
❑ 'FIR>
IAARCE
DEPS
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑�
❑
submittal of Building Permit application.
MfAJOR
8ANITAItY9EWERDISTRICT,
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
19 ADDRESS: 20700 STEVENS CREEK BLVD
DATE: 1211512015
REVIEWED BY: MELISSA
PC FEES
APN: 359 08 028
BP#:
*VALUATION: 1$97,000
A•PERMIT,TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
USE: Commercial Building
$2,160.12
PENTAMATION
PERMIT TYPE: 1 B TA
WORK
EVER SMILE - T.I. TO RECONFIGURE 1,470 S.F FOR NEW DENTAL OFFICE M.E.P.'S
SCOPE
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
(s.f.)
PC FEES
PC FEE ID
BP FEES
BP FEE ID
B (Tenant Improvements)
II-B,111-B,IV,V-B
1,470
$2,160.12
IBTIPLNCK
$1,408.32
IBTIINSP
PME Plan Check:
$0.00
Permit Fee:
$1,408.32
Suppl. Insp. Fee:Q Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
(.."onsfl'7LC.'t"on Tcn':
TOTALS:
1,470
$2,160.12.;
; F_ -
$1,408.32
MECH,,'HOURILY Yes ,No-
PL°UMM HOURLY Q Yes � Q No `.
ELUC, HOURLY-°
`Q .Yes No`
Alech. !'Tart Check
Plus rb. flan ("Izec.&77�
jaer;..a'Grr, (.heck
PerPni! tree:
I'!tf nb. Pei nii t'f'e:
Lit(?;;, l�('?'7Ptfi PCC.
ElOr:hr
Ptltlir() ?N'.57:,
Ll
i.iil iC'.% I:ir.`C". IY:S,s"Ll
hrs
1'IWilb. hts.v,
PME Plan Check:
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 only an estimate. Contact the Dent for atldn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/11.13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,160.12
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (D Reg. COT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,408.32
Suppl. Insp. Fee:Q Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
(.."onsfl'7LC.'t"on Tcn':
:idmdlfisf 'alit,( Pee:
0
E)
Work Without Permit? 0 Yes Q No
$0.00
Advanced Planning_Fee:
$0.00
Select a Non -Residential
Building or Structure
G
0
/. i rz✓e/ ilcr<;ur,tLTrtczP�z3ar .F ecus;
Strong .Motion Fee: IBSEISMIC0
$27.16
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$4.00
SUBTOTALS:
$3,599.60
$0.00 .TOTAL FEE::
$3,599.60
Revised: 10/01/2015
C.,-C-Acc'-4-
7YNU�efz- /6-Aac'-A
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: t3 j v PERMIT #"15/2-0111q
OWNER'S NAME: Pm (nq ( o �PHONE ## 15 -' & 79W -•,/
GENERAL CONTRACTOR: Uo BUSINESS LICENSE #1
ADDRESS: 0t CITY/ZIPCODE: I J ' q90A
*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
Ad /41'/11 - '2 (/ � /�'
Owner / Contractor Signature Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork�p
-i V..,p k
77
Cement Finishing
W22-76 76 Ll
Electrical
K
j (�
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Ntli►.S
C1
Insulation
Landscaping
Lathing
Masonry
.,
Painting/ Wallpaper
jG CJ�
Paving
Plastering
Plumbing
I- ��ji�
Roofing
Septic Tank
Sheet Metal
Sheet Rock,
Tile
Ad /41'/11 - '2 (/ � /�'
Owner / Contractor Signature Date
02/12/2016 8:08 M FAX 14088666043
DUPLAN CONSTRUCTION INC Wj 0001/0001
Building Department
City Of Cupertino
10300 Tone Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR, / SUBCONTRACTOR LIST
*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 Date
Please check applicable subcontractors and complete the following information:
:z
SUBCONTRACTOR
Cabinets & Millwork
Cement Finishing
Electrical
BUSINESS NAME
s& .P*,<,
BUSINESS LYCENSE #
/a -76 q
3 (�
Excavation
Fencing
Flooring/ Carpeting
Linoleum / Wood
Glass / Glazing
Heating
S .T��
Cl
Insulation
Landscaping
Lathing
Masonry
.,
Painting/ Wallpaper
.
5 CD le
Paving
Plastering
Plumbing
1 i In
Roofing
Septic Tank
Sheet Metal
Sheet Rock
rJ
Tile
A.,,,I mz,�Z-� C / /�--
Owner / Contractor Signature Date
HAZARDOUS MATERIALS CHECKLIST
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org
r E51 V l� � c" IE;
PURPOSE
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.
>C
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 otherC,
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.
�C
10. Commercial pool systems.
11. Chemical Storage areas.
12. Flammable liquid storage.
13. Compressed Gases.
X
14. Dry cleaners.
�(
15. Print Shops.
16. Auto Repair and Auto Body Shops.
x
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 03/07/11