B-2016-1802 • CITY 0' : JPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1802
10310 S DE ANZA BLVD CUPERTINO,CA 95014(369 55:081) OMEGA
CONSTRUCTION
SAN JOSE,CA 95117
OWNER'S NAME: CIVIC PARK CUPERTINO LLC DATE ISSUED:06/02/2016
OWNER'S PHONE:408-318-4235 PHONE NO:(408)605-8113
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B ic.#586016
Contractor OMEGA CONSTRUCTION Date 01/31/2018 X BLDG _ELECT _PLUMB
X 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
license is in full force and effect. JOB DESCRIPTION: •
ARIRANG TOFU&BBQ T.1.-CONVERT(E)PIZZA OVEN TO
I hereby affirm under penalty of perjury one of the following two declarations: COOKING AREA WITH(N)EQUIPMENT-ARIRANG TOFU&BBQ
t. 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-REVISE HOOD CONNECTION DETAIL-ISSUED 7/5/2016
performance of the work for which this permit is issued. REV#2-REVISE MECHANICAL UNIT AT ROOF-ISSUED 9-18-2017
I have and will maintain Worker's Compensation Insurance,as provided for by
6�_Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION Sq.Ft Floor Area: Valuation:$30000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 369 55 081 A(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
may accrue against said City in;consequence of the granting of this permit. PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally,the applicant understands,and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code,Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signat ., Date 09-18-2017
Issued by:Abby Ayende
OWNER-BUILDER DECLARATION Date:06/02/2016 •
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:' RE-ROOFS:
1. I,as owner of the property,or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed.If a roof is
compensation,will do the work,and the structure is not intended or offered for installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed
contractors to constructjthe project(Sec.7044,Business&Professions Code). Signature of Applicant:
Date:09-18-2017
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work'for which this permit is issued. k
2. I have and will maintain Worker's Compensation Insurance,as provided for by HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code,for the performance of•the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the
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 1 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
Worker's Compensation laws of California. If,after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
• exemption,1 become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino.Municipal Code,Chapter 9.12 and
Labor Code,I must forthwith comply with such provisions or this permit shall the Health&Safety Code,Sections 445,25533,and 25534.
be deemed revoked. I 1
Owner or authorized age °: —
APPLICANT CERTIFICATION Date:09-18-2017
I certify that I have read this application and state that the above information is CONS RUCTION LENDING CY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lendirig agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
' to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name i
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. I understand my plans shall be used as public records.
Signature Date 09-18-2017 Licensed
Professional
• CONSTRUCTION PERMIT APPLICATION
\\\ / B
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
rillik
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
40 s (408)777-3228 • building@cupertino.org PEMIT#B-1/9 - I 0 2-
CUPERTINO REV#1 DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION"❑ I. El MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS 1%03 ,pq r3,V cF APN I
•
OWNER NAME PHOT , ?I , EMAIL
• STREET ADDRES1 V 7 0 S_ ue /yVv ^ 131 CITY,STATE,ZIP ^M 0 9 s 6/ / j
jg:CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME,AT1 C LICENSE NUMBER UMBER LICEIN`SE(/-TYP
ISTREET ADDRESS L: ` / �- A� tT CITY,STATE, ZIP ` '( 7 I
E-MAIL I (_GHOI4E l`�Y` BUS.LIC I
Q' Ar17 -IcFen
• ,,,,( ob\om �' ) .Cod ` --RIO
0 ARCHITECT ❑OWNER ❑OWNER AGENT IE,CONTRACTOR AGENT❑ENGG EER 0 DEVELOPER 0 TENANT
CONTACT NAME E-
Lit,,\IQ ---' eP 4
y_
STREET AD SS 1 041E_
��1 1 CITY S E 1 C.a_q1 7 PHONE)�' J oca %� i S
DECRIITON 4,,,A,q X4- -g0l-__((1 iD.,,,L. -0„..,_g- / ix,,A,-,,d, . PT: : ' \ 5 (Bi( �N -I— l YYY
❑SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ❑INDUSTRIAL ,COMMERCIAL P I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES I TOTAL NET SF USE TYPE OCC, SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED ,
EMSING ❑YES EICHLER ❑YES SECOND STORY ADDITION O YES
FIRE SPRINKLERS 0 NO 0 NO NO
DWELLING SECOND DWELLING ❑YES 0 ATTACHED 0 DETACHED OTHER
UNITS# UNIT ADDITON: 0 NO S F
POOLS! ❑FIBERGLASS ❑VINYL-LINED ❑GUNITE ❑PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED❑YES 0 NO TOTAL-SF e '
REE/BY TOTAL VALUATION:
Commercial or Multi-Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval
n(
Q
RE-ROOFI EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD ❑'1/2" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
❑YES Ii OF LAYERS THICKNESS❑5/8" OTHER ❑OSB El CDX OTHER •12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF EASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES ❑OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF ! #of SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act 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 verify it is accurate. I agree
to comply with all applicable local ordinances and state laws rela i;g to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection purpose .tT"w tea- and authorize all information contame.;on t 's application form
to be made available for public record. Q
Signature of Applicant/Agent: �'��� Date: 6� G 1 't
1SUPPLEMENTAL INFORMATION REQ RED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure.form if any Hazardous Materials are being used'as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
•
BldgApp_2017.doc revised 08/01/17
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Bldg.4py ?0/1 di�r,revised C6/21/li
CONSTRUCTION PERMIT APPLICATION �
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255
GURERTINC7 �408)777-3228• FAX(408)777-3333 • buildinaCa�cupertino.ora t`: rq��
`�'ZC�1�D ' ° ��J � I
❑NEWCONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION/DEFERRED ORIGINALPERMIT#
PRO]ECTADDRESS '�ry I� �` ^�y APN# �XP� ���I
�7 �✓!� J�"��
OWNERNAME �`� PHONE �. &MAIL J�
/
STRE&TADDRESS �O ��� S` �y Q�r ( CITY, STATE,ZIP� �W �A QQO /tL FAX
,�/ 1� C Cl� [� � j
CONTACT NAME � r./�, PHONB �� �I� ,�„�� 6-MAIL/�/. J�a � �ry �/ � `
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❑OVJNCR ❑ OWNER-BUILDE2 ❑ OWNE2AGENT ❑ COMRACTOR ❑CONTRACTORAGLNT ❑ ARCHTTECT ❑HNGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAMH LICENSENllMBER GCENSCTYPG ➢US.UCA
COMPANYNAMG GMAIL AAX
STREET ADDRESS CI1'Y,S'CATB,ZIP PHONE
ARCHI7'SCT/ENGMECRNAME �� JM LIC NS&NUMRH2C` Ly j�J � BUS.LIC#
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COMPANY NAME E-MAIL / ,,._ e ` / `_� FAX
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DESCRIPTION OF WORK � ��n I`N`
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E STW USC PRO SG� 55 CONSTR.TYP9 RSTOR�S USE TYPE OCQ SQ.FT. VALUATION($J
y tir�. � 3
EXISTG NEWFWOR DEMO TOTAL
A2EA AREA AREA NETAREA
HA99JROOM KITCHHN OTIdIXt
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Ey my signalu�e below,I certify to each of the following: 1 am the piroperiy owncr or zathonzcd agent lo act on lUe roperty ownei's behal£ I have read this
application and the mfornr.itlon I have provided is correct I l�ave�end the Descrip[ion of Work and veiify it is aoourate. 1 agree to eomply wil(i all applieable local
_ oidinances and slete laws�clapng to biiilding oonshuotion. I aulhoiize�epiesentatives oPCuper[ino fi enter the above-ideurified propeiiy fur inapecdou purposes.
Sig��ature of ApplicanVAgent• Uate: o
SUPPLEMENTAL ATIONREQUIRED r�aicxecxTima-' ao[rrmcscir
New SFD or Multifamily dwellings: Apply for demolition pennit for ❑ ovEa it�courvrex�- ❑ aun,omcrLniarzE��aw
existing buildiug(s). DemoGtion pemtit is required prior to issua�ce of buiLding �
peimit for new building. ❑ exrxess ❑ vLnnrvwc e�,iiq aev��i�
a
Commercial Bldgs: Provide a compleled Hazardous Materials Disclosure ❑ s'rarauaau = ❑ rus�ic�voaKs
fm�n if a�ry Hazazdous Materials are being used as part of this project. ❑ 'cnace'�� ❑ c�rzc usrT
IR
Copy of Plannivg Appcoval Letter or Meeting witli Planning l�rior to p ,y,��oa ❑ sen�rndr seNExn�sxwcr '
submittal of Building Pennit applica6on. _.: -
❑ ENVIROMI4EHTALdEALTII �.
BldgAyy_2011.doc revised 06/21/11