08090108 Idl
a ar
O F F-
O p4
A 3
(7 �0
a zn ar
pq
V F O
O pq h
m U '� d
U o-7
{[ H
fS a F
LC7 F U
CD
w a
F
{L a ur
CS a
a
0 w a
p ca
w a x
J J
t
.2 A `"+
L3
o z z o a
Ir C''i U F p7 •--I
w CL cv a O
J J = O O 7u pq W N
O O d LO _ N F U) N
z F-O n CL Z
LO o q� A
M pC o -i ��-CD u a- 0 p` v a
�- N CSD - > 11 m U EL H H
C7 Z 3 F H p4
U m CL
xa) a
z�
E
al LO
d a cp _0
U d 1O d U
Idl
v
� m
'L• n n v,
xo
U
y U
.•.11, al L
- z v 16 v v ICSI ICSI ICfl a v
n F n n n
v O O O U a
_ p i L
Idl LLJLA_p M o �;;IICD a o
LU Ln_ w a 7 o w Q L c
CD
•deY n
O U d I Lr a C j •O
ID w
�. ti c w Ir M O
00 LL-oo _0 o 0 o F- (M F- w d o 0
CD Q) CD CD CDp i
o o` LL 10
LLJ
U LN N F - ti F - d al
m w C �, O r- w n
co U O O O >-
(DQ C
N z 6 (u 0 n x x x0 ip n O O
n `f
o v0 a o a v, l w _0 xE n N a) o
E E x0 ~ Q7 ' r j 7 w al o `O t o � n
n O
x� O U y E rn fu
v U E .y u n
al a`l a o m r_n u`l > y
.7, W 0 �o 'D •O a Ql •Ql •01 Ql a- d d Cil U a- O a- fu
C
0 [n c d d U U U a_ al
O
>_ W U
�
CITY OF CUPERTINO
BUILDING DIVISION PERMIT � TkTfi7R Z � TIQNr
BUILDING ADDRESS: PERMIT NO.
10123 N WOLFE RD J T CONSTRUCTION 08090108
OWNER'S NAME: PERMIT I5SUE DATE
CUPERTINO SQUARE LLC 1720 OCALA AVE STE B 10/10/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 234-4340
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u 0 o LICENSED CONTRACTOR'S DECLARATION O O O
u F 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Zw with Section 70(10)of Division 3ofthe Business and Professions Code,and mylicense's TI FRONT ENTRY DOORS FOR MALL' ENTRY ICE CENTER
y in full force and effeCL
License Class Lie.# DOORS. INCLUDES ELECT/MECH/PLUMB & STRUCTURAL.
Contractor
3 F to Date ARCHITECTS DECLARATION 1500 SQ FT.
4 < 1 understand my plans shall be used as public records
D,U
VO y Licensed Professional
y S OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
00 following mason.(Section 7031.5,Business and Professions Code:Any city or county
K,�a fi which requires a permit to construct.alter,improve,demolish,or repair any structure
n Z aprior to its issuance,also requires the applicant for such permit to Ole a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation-
Y.F$ (commencing with Section 7000)of Division 3 of the Businrss and Profrssions Code)or $75000
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of A�.�. umber Occupancy Type
not more than five hundred dollars(5500). 3 16 2 0 0 9 6 ,!'IFIL
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure isnot intended oroffered for sale(See.7044.Business Required Inspections
and Professions Code:The Conuactoes License Law dots not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
anlI as owner of the property,am exclusively contracting with licensed contractors to
struct the project(Sec.7044,Business and Professions Code:)The Contractoes Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects 'h a contractor(s)licensed pursuant to the Convector's
License Law.
ElI am exempt ups a i.. ,B&P C for is on
i
Owner 4 ; Dale
WORK 'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insum for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workees Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nhis section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify Uhat in the per(o the �'or wfi this permit is issued,1 shall not
employ any person in an h so m •omc j`ct to the Workers'Compensation
Laws of California.Da
Applicantfly 11f IvLq.Ar 11
NOTICE TO APPLICA :If.after making this Certificate of Exemption•you should
become subject to the Worker's Compensation provisions of the Labor Code,you mast
�Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
Z
I hereby affirm that there is a construction lending agency for the performance of
(Y.? the work for which this permit is issued(Sec.3097,Civ.C.)
WCL Q Lender's Name
Z Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
[L '•—' cortecL I agree to comply with all city and county ordinances and slam laws relating to
0 building construction,and hereby aulhorim representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
o.4 f/) liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z A PLIC rrencc of UnUlWrLI
/D
APPLICANT U TAOMPLY WITH L ON-P INT Issued by: DateSOURCEREG NS.
!/ VVV r roofs
Signature of plica&/Contractor Da
HAZARDOUS MATERIALS DISCLOSURE Ty Type.of Roof
Will the applicant or future bulding occupant store or handle hazardous material
as defined by the Cupertino MFJipal Code,Chapter 9.12,and the Health and SafetyCode.section25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as,defincd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
I have read the haza6ous materials req' mens under Chapter 6.95 of the Califor-
nia HcalUh&Safe ode,San ,
,255 3 and 25534.1 understand if the ilding '
does not curter resm respoasihility to notify occup of the
reyuiremcnts th 's ` of aCertifhca ea ry. Signature of Applicant Date
Owner or futhorized agent te'
All roof coverings to be Class'J�{`'or better
DY
CITY OF CUPERTINO
TENANT IMPROVEMENT
CUPERTINO PERMIT APPLICATION FORM
AP]v # � � ��� �. �� �L� Date: 9 J
G
Building Address:
ter_
Mailing Address (if different from building address):
Tenant R (If tenant please provide a letter from the building owner approving the tenant improvement.)
Building Owner ❑
Tenant/Building Ower's Name: Phone
(9_X V1'1'vt �' 1 !"I�k�L PCU �'l�l't'
Contractor: Phone#:
J f
J'( C&I"`�77 �'1-( Fax #:
Contractor License#:
Cupertino Business License#:
Contact: ` r Phone#: Li DS-�" 17 7 - 36V
Fax #: 7 Z - 0_& 7�
Alternate Contact: Phone#:
Fax #:
Valuation (cost of project): t
,S0Q
Job Description (be specific): �� ��•�����.� ` ti �__[ f
l50a
Tenant Improvement Includes Re-Roof. Yes ❑ No ❑ If yes, number of squares
Tenant Improvement Includes Structural Yes ❑ No ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A P""II/III B, IV-HT, V-B ❑ — Z
Project Size: Express ❑ Standard E Large Major
Green Building: Please complete Leed for commercial interiors checklist & attach it to the application
or if applicable, include in plans & sheet index
LEED Points Achieved
*** For Office Use Only*** Over The Counter ❑ Revised 8/08/08
�. Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: i 1,,ck lea 11 R PHONE # '777 3031
GENERAL CONTRACTOR: ,� C c�, - �,� .- FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
4 }f
W1 `� l
Owner/Contr for Signature Date