150400249h n i,. CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: N WOLFE RD `lTt: �b� ICCONTRACTOR: 1ON TRUCT ON INTERSTATE UP I PERMIT NO: 15040024
1 OWNER'S NAME: CUPERTINO VILLAGE LP 1437 29TH ST NE STE F I DATE ISSUED: 10/01/2015 1
OWNER'S PHONE: 4252090156 1 PUYALLUP, WA 98372 1 PHONE NO: (253) 435-0949 I
Ilm — LICENSED CONTRACTOR'S DECLARATION
License Clas -. ic.
SN 1i 44 a mt K [.A-` o s*
Contractor _ , Date
I hereby affirm that I aullicensed 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:
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
5tion
formance of the work for which this permit is issued.
2,ve and will maintain Worker's Compensation Insurance, as provided for by
3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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 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,
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 egulations p e Cupertino Municipal Code, Section 9.I8.
Signature ��.: ,.: ° • Date +
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
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
sale (Sec.7044, Business & Professions Code)
2. 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
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
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
permit is issued.
3. 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
become subject to the Worker's Compensation provisions of the Labor Code, I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
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 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,
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
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
MOD SUPER FAST PIZZA- COMM T.I INTERIOR BUILD OUT
TO INCLUDE M,E,P'S (CUPERTINO VILLAGE)
Sq. Ft Floor Area: Valuation: $192000
APN Number: 31605052.10869 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date: 100 I
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, l agree to remove all new materials for
inspection.
Signature of Applicant:_ Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner �ar 1%r gent:.
f
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 950143255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION 1�7J ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECTADDRES North Wolfe Road x90
APN#
vv
�
osa ,
OWNERNAME MOD Super Fast Pizza, LLC
E-MAIL
STREETADDRESS:11 r Ciro- �
:. 0ESI:.^.:.-I— f ,�'1l. ;
^ I � o 00n:C
CITY, , iAlA STATEZIP Kol
FAX
•L • I •�/... ♦Jl LI l-L� t/L IJ LJ. �.. //LVL
✓l-t.l- 4l-, / /VV VJ
CONTACT NAME Daniel Choi
PHONE 310-275-7774 E-MAIL daniel@permitadvisors.com
STREETADDRESs 8370 Wilshire Blvd Ste 330
CITY, STATE, ZIP Beverly Hills, CA 90211
FAX
❑ OWNER ❑ OWNER -BUILDER it OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
srREET' ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECTIENGINEERNAME Scott fay fOhnson
LICENSE NUMBER C - -1i!)63
BUS. LTC#
COMPANY NAME Graphite Design Group
E-MAIL
FAX
STREET ADDRESS 1809 Seventh Ave, #709
CITY, STATE, ZIP Seattle; WA 98101
PHONE 206-519-5132
DESCRIPTION OF WORK
Interior build out of an existing space in a multi -tenant single level building.
Work includes non-structural partitions, suspended ceilings, casework,
finishes, food service equipment, mechanical, plumbing, & electrical.
EXISTINGUSE PROPOSEDusCONSTRDT`...
mz 0STORIES
Restaurant
II -Q 1
USE
TYPE
OCC.
SQ.FT.
VALUATION($)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NETAREAL,:)I»F
BATHROOM KITCHEN
OTHER
REMODEL AREA REMODEL AREA
REMODEL AREA
PORCH AREA
DECK APEA
TOTAL DECKUPORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
# DWELLING UMTS:
IS A SECOND UNrr ❑ YES
SECOND STORY ❑ YES
BEING ADDED? [:]NO
ADDITION? ❑ NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED BY:
TOTAL VALUATION:
PLANNING APPL 4 ❑NO PLANNING APPROVAL LETTER
EICHLERHOME? r] NO
192,000
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 relating tolalildiar censtnlction. I authorize representatives of Cupertino to enter the above- identified property for inspection purposes.
Signature of Applicant/AgenDate: (�
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE ROUTING SLIP
EJOVER-THE-COUNTERDIITI,DING PLAN
—New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
REVIEW
permit for new building.
❑ EXPREssPLANNING PLAN'REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
STANDARD ElPuDL[c woRKs
form if any Hazardous Materials are being used as part of this project.
El
LARGE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑
submittal of Building Permit application.
MAJORANITA Y SEWER DISTRICT
ENVIRONMENTAL HEALTH
BldgApp 2011.doc revised 06121/11
CITY OF CUPERTINO
iD!(e/ FEE ESTIMATOR — BUILDING DIVISION
imADDRESSa4686Tn
wolfe rd 5k��
DATE: 04/03/2015
REVIEWED BY: Mendez
PC FEE ID
APN:
BP#:
*VALUATION: 1$192,000
*PERMIT TYPE: Building Permit
PAN CHF K TYPE: Tenant Improvement
PRIMARY Commercial Buildi
USE: ng
ATIPLNCK
PENTAMATION 1A TI
PERMIT TYPE:
WORK
mod super fast izz- comm t.i interior build out to include m e 's
SCOPE
Suppl. Insp. Fee:Q Reg. Q OT
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
A (Tenant Improvements)
II-B,111-B,IV,V-B
2,575
Other- Plumb Insp.Li
ATIPLNCK
$1,467.57
IATIINSP
Elec. Imp. Fee:
$1,467.57
Suppl. Insp. Fee:Q Reg. Q OT
0,Qhrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax:
,1cllnlnistrative .Tee:
Work Without Permit? 0 Yes (j) No
$0.00
TOTALS:
2,575
$2,521.09
7?avel Documentation Fees:
$1,467.57
a�
1VIECH,;HOURLY Yes No`
PLJMS,,HOURLY „Qp Yes�iIo`
EZE'C, HOURLY;- Q Yes RsNo
Mech. Plant Check
Phinib. Ilan Che ,k
L7ec..Plan Check
rblech. Perini! Fee:
Plumb. Permit Fee:
Glee. Permit Fee:
Other Hech. Insp.
Other- Plumb Insp.Li
Other Glee. Insp.
Alech. Insp. Fee:
Pian b Insp. _Fee:
Elec. Imp. Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E f 7111131
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,521.09
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (j) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,467.57
Suppl. Insp. Fee:Q Reg. Q OT
0,Qhrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax:
,1cllnlnistrative .Tee:
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee:
$0.00
Select a Nin -Residential
Building or Structure 0
i
7?avel Documentation Fees:
Strong Motion .Fee: IBSEISMICO
$53.76
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$8.00
$4,050.42,
$0.00k TOTAZ�FE2
Revised: 02/14/2015
JA I,- CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 16869 N WOLFE RD cS' 12969 I CONSTRUCT CONTRACTOR: INTERSTATE I PERMIT NO: 15040024GROUP I
OWNER'S NAME: CUPERTINO VILLAGE LP
OWNER'S PHONE: 4252090156
❑ LICENSED CONTRACTOR'S DECLARATION
. Y
License Cl?7 Oams'-- \-
Contractor �/_Pate
-,
F '">'.?S,Ci,E�.r_
I he e y affirm Y[ at— 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:
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
erformance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance, as provided for by
.tion 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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 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,
costs, and expens which may accrue against said City in consequence of the
granting of thi rmit. Ad itionally, the applicant understands and will comply with
_s z VFfi*3- F
Si nat e "r
all non point r e regul i upertmo Municipal Code, Section 9.18.
J
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 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)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
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
Compensation, as provided for by Section 3700 of the Labor Code, for the
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
permit is issued.
a. I certify that in the performance of the work for which'this permit is issued, I h�"a 1
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
become subject to the Worker's Compensation provisions of the Labor Code„ I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
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 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,
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
437 29TH ST NE STE F I DATE ISSUED: 10/01/2015
PUYALLUP, WA 98372 I PHONE NO: (253) 435-0949
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
MOD SUPER FAST PIZZA- COMM T.I INTERIOR BUILD OUT
TO INCLUDE M,E,P_S_(CUPERTINOVILLAGE)
REVISION # L.
Sq. Ft Floor Area: I Valuation: $192000
APN Number: 31605052.10869 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE. OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Date: ,z%/ 'RZ zJ .
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & ty ections 25505, 25533, and 25534.
Ow '-o ' a
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
l j"�'o -*
CONSTRUCTION PERMiT APPLICATION
COMIMILINITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPi_RTINO (408) 777-3228 • FAX (408) 777-3333 • buildina .cuDerlino.or
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI VISIO DEFERRED
ORIGIN?AL PERMIT T o
PROJECT ADDRESS S
OWNERNAIVIB t � PHO' r rM
t•
E-1✓SII.
Q
STREET ADDRESS CrTY, STATE, ZIP I� I FAX
` \ c ab�
CONTACT NAME PHONE E -M.
STREET ADD! CITY, ST �v_ \ - + d� �1
FAX
OVNIER R ovNER-BuIDER r,01VNc'Pr El CONTRACTOR El CONTRACTOR AGa'r ❑ A..RCCHITECT ❑ ENGINz.-R ❑ DE\z-LOPe.R ❑ TPNAhT
CONTRACTOR NAME LICENSE NU,' ER LICENSE TYPE
V
I BUS. LIC 4
COMPANY NA1,M
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHrTECTrtNGIN, EER NAJ✓ELICE NSF NFIJhG;ER r � �
✓✓�
BUS. LIC I
COMPANYNAAS�
E-MAIL
FAX
STREET ADDRESSA-7 (n
CITY, STATE, ZIP - pS\ �O�
PHONE
`
�I
r
SIL
1NIS,
DESCRIPTION OF WORK � a Ja co =i tv
EXISTD7GUSE PROPOSED USE I CONSTR _ 4STORIES
..v
USE
TYPE OCC.
SQ.FT.
VALUATION (S)
EXIAMA
AREA
NEW FLOOR DEMO
AREA AREA �
NcT AREA
TOTAL 9� -5
r
2,5 V
BATHROOM KITCHEN
OTHER
R 1,40DEL AREA REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECKTORCH AREA
GARAGE AREA: LJ DETACH
❑ ATTACH
D', rTLLINGUNIT'S:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑YES
BEING ADDED? ❑NO
ADDITION? E]NO
PR.E-APPLICATION ❑YES IF YES, PROVIDE COPY OF
Is THE BLDG A.N ❑ 1 tS
C 'IZED M:= _
TOTAL VALUATION:
PLA.NIR 'G.4PPLm F-11,10 PLANN�GAPPROVAL LETTER
EICHLERHONIF? ❑NO
= - - _
By my signature below, I certify to ea0of'e followi g: Iamthe property owner or authorized agent to act on the property owner's behzIf. I have re d this
application and the information I haveed is cc eet, I have re •the Description of'Work and verify it is accurate. I agree to complyWith all applicable local
ordinances and state laws relatin.- to bconst ut e r resentatives'of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENT ON IRED . �
P.,—
o��R raEcoiJ�TER
-
�7rBUIIDLIGPLANREVZEiP
New SFD or Multifamily d-,vellings: Apply for demolition permit for
existing building s). Demolition permit is required prior to issuance of building
_
permit for new buildina.
PI 4'�NLtGPL4N RE�ZEFi -
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
_
-,
PUEicuoRxs =_
iM STA BARD -
_
form if any Hazardous Materials are being used as part of this project.
LtG> =
_ Copy of Planning Approval Letter or Meeting with Planning prior to
T
NL470R
=
S�iNTTIiRYSEiiER�ISTRIC�C9
submittal of Buildir_g Permit application.
Bla'gtlpp_2011.doc revised 06/21/11
MA
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR DIST
JOB ADDRESS: i
PERMIT # 00
OWNER'S NAME: AA nor
PHONE # Rss `
GENERAL CONTRACTOR: � ;s
USINESS LICENSE #
ADDRESS:'` -,r,�
CITY/ZIPCODE: '
*Our municipal code requires all businesses working in the city to have a City of uupertmo nusiness ncense.
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:
t
wn / Contractor Signature
Do t (p
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
-�' jam- - ;,
Electrical
RL
(o c
Excavation
Fencing
Flooring / Carpeting
%� f
Linoleum / Wood
Glass / Glazing
Heating
, '
c
Insulation
Landscaping
Lathing
A
Masonry
Painting/ Wallpaper
2-(, 3 Lit In,
Paving
Plastering
UA
Plumbing
Roofing
v
Septic Tank
Sheet Metal
Sheet Rock
Tile
--
t
wn / Contractor Signature
Do t (p
Date