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B-2016-2081CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2081 19499 STEVENS CREEK BLVD CUPERTINO, CA 95014 (316 20 112) W L BUTLER CONSTRUCTION INC REDWOOD CITY, CA 94062 OWNER'S NAME:, MAIN STREET CUPERTINO AGGREGATOR LLC DATE ISSUED: 06/07/2016 OWNER'S PHONE: 612-761-5726 PHONE NO: (650) 361-1270 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class IL Lic. #355353 Contractor W L BUTLER CONSTRUCTION INC Date 03/31/2018 X BLDG _ ELECT _PLUMB MECH RESEDENTIALXCOMMERCIAL 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 fug force and effect. JOB DESCRIPTION: T.I. PREP (21,050 S.F.) - TARGET EXPRESS I hereby affirm under penalty of perjury one of the following two declarations: T.I. PLAN CHECK # B-2016-1675 1. I have and will maintain a certificate of consent to self -time for Worker's _ts 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 Cade, for the performance of the work for which this Sq. Ft Floor Area: Valuation: $10000,00 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 APN Number: Occupancy Type: and state laws relating to building construction, and hereby authorize 31620 112 A (Tenant Improvements),A (Tenant Improvements),A representatives of this city to enter upon the above mentioned property for (Tenant ImprovementsIA (Tenant Improvements),A inspection purposes. (We) agree to save indemnify and keep harmless the (Tenant Improvements),A (Tenant Improvements),A City of Cupertino against liabilities, judgments, costs, and expenses which (Tenant Improvements),A (Tenant Improvements),A may accrue against said City In consequence of the granting of this permit. (Tenant Improvements),A (Tenant Improvements),A Additionally, the applicant understands and will comply with all non -point (Tenant Improvements) source regulations per the Cupertino dunicl [-Code, Section 9.18. "'! o 6 PERMIT EXPIRES IF WORK IS NOT STARTED Signature Data WITHIN 180 DAYS OF PERMIT ISSUANCE OR OWNER-BUILDERDECLARATION 180 DAYS FROM LAST CALLED INSPECTION. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Issued by: Abby Ayende r. I, as owner of the property, or my employees with wages as their sole Date: 06/07/2016 y"kN��e,4iULC compensation, will do the wok, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Cade) RE -ROOFS: 2. I, as owner of the property, am exclusively contracting with licensed All roofs shall be inspected prior to any roofing material being installed, If a roof is contractors to construct the project (See.7044, Business & Professions Code). installed without fust obtaining an inspection, I agree to remove all new materials for I hereby affirm corder penalty of perjury one of the following three declarations: inspection. r. 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 Signature ofApplicant• performance of the work for which this permit is issued. Date: 2 1 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER permit is issued. 3. 1 certify that in the performance of die work for which this permit is issued, I HAZARDOUS MATERIALS DISCLOSURE shall not employ any person in any manner so as to become subject to the I have read the hazardous materials requirements under Chapter 6.95 of the Worker's Compensation laws of California. If, after making this certificate of California Health & Safety Code, Sections 25505, 25533, and 25534. I will exemption, I become subject to the Worker's Compensation provisions of the maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Labor Code, I must forthwith comply with such provisions or this permit shall Health & Safety Code, Section 25532(a) should I store or handle hazardous be deemed revoked. material. Additionally, should I use equipment or devices which emit hazardous air commensals as defined by the Bay Area Air Quality Management District I APPLICANT CERTIFICATION will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I certify that I have read this application and state that the above information is the Health & Safety Co , Sections 255 5 533; and 25534. 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 Owner or authorized agent: to save indemnify and keep harmless the City of Cupertino against liabilities, Date: 6/7/2016 judgments, costs, and expenses which may accrue against said City in CONSTRUCTION LENDING AGENCY consequence of the granting of this permit. Additionally, the applicant understands I hereby affirm that there is a construction lending agency for the performance and will comply with all non -point source regulations per the Cupertino Municipal of work's for which this permit is issued (Sec. 3097, Civ C.) Code, Section 9.18. Lender's Name Lender's Address Signature Date 72016 ARCHITECT'S DECLARATION LoCONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIONts 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 ` 1 CUPfwR 0 (408) 777-3228 • FAX (408) 777-3333 •2uliding cupe tino.org �' 1�1(0 -26$� 1-1 Nrw CONSTROO170N ❑ ADDITION AXJ AUFFRATION/'CI (.I RIiVISION /1)[3]'C>RRlit> ORHANALPERMITO T fMIN it PROJECT ADDRESS WifflAAMRS OWNER, NAML' 'r PHONE END I. i — 7 1-5 72 �� CRet4 �(}�rry p STIU±G'f n00Rf?S5 j �� . �� etY srA,rr ztF ,.' V,+ } �J'+-MAIL IrAx CONIAOT NAME 7 PHONE 'tGi Ijp+ t 1Z 1 r le .r� err-��rn STRGC'TADDRESS Ir.00 i)"11�I((( CI Y, S1A'tC• SP rnx . t� OWNER Q OWNERAUILDER yr.OtVNRR AGmT Q CONTRACTOR Q COffiTRACIOR ADPW 0 Aacarmci, Q ENGINEER Q Drvin OPER Q 'ITNANi' OO11TRACP0k NAA41i { .5 �i,y �D�Y } UCY?N91i NUMAF.R LIC4't SI, I'YPA (L J✓�}y'1y :./ BUS. 4.IC 11 1/ COMPANY NAME--4��W///V{1 EMAIL FAX "JO ry 6'rRan'ADD " _. Y C(TY.aTr T z" t VF th ' N`0� i PPIUNIA �rl ✓ � ! -�/) �� ARCHURCTMN IINERR NAME 4 ath'R-wLs )� rl(IENNENOMBER 4 �^� � m (r, 4 L^ J HUS. LIICjR COMPANYNAMR C:MAH, FAX S'MEET ADDRESS o J�CITY, 'A/.A '( N!l' _AAot DESCRIPTION Or, WORK ynUll-s ( OTAtit EXISt[N ;; - MtOPo5nii-vif; CONSTRANPE NS'FORIE Nn�/ '7 fro}% ( USE TYPE GC.C, G ! SQ:Er1 VALUATION(.S) PSISTG _ 'r'Wttl.ofok T)HMO�% 'TOTAL AREA ARFa1 a } ARVA 7 d v �J Nnr AREA ,030 JA'1%ROOM KITCrnN OTHNR REMODEL AREA AEMODE1. AR EA mdMOA1n.APEA 1roRCH ArtEA DfCK r1REA TOTALllGCKIPORCN NtGA- G1R 1Ct \RCA: [TATrACII APGICPI a 6lVrlA.ihG UNIT S' UNI'P YA3 SF(ONDSr0R�1�[]YI4'-^ HVINEDDNn RRINf AnnEm? QtwO^ Aoni910N? ONO PRC-AITLIOA'I'IpN YRS O YAS, PROVIDG COPY OP is'I uli 6LAC AN QY6S LL -111771 V&-IIY; 'f077iL VALUATION: PLANNINOAPPLa ONO PLANNING APPttOVALi.ETfAR Elcu LMtilomE? ONO o+. fly my signaUlrc b¢Iav, [ cerlily to each Af tho following; 1 nm the.property owner sr Rutliorizod agent to Oct on he pm erlyowner's behalf. I have read this nptincation and tho information I have Provided is correct. I have road the Description of wArk and Verity it isnccurate. I agree to comply with till applicable loan ordinances and state laws relating to building Most r Iction. I authorize rcprasanmoves of Cupailmo to enter the Oboe e-idendfic( nnperly for inspection purposes. Signature orApplicani/Agen[ SUPPLEMENTAL INFORMATION IfEQUiR1351'IafN4ItEGK Ti(CE It0VCNORILIP New SFD or Multifamily dwellings: Apply for demolition permit for [} GVEIVIII&COUNfER 0 BUILDING PLAN KNVIE M existing building(s). Demolition permit is required prior to ESSuanoe of building _ permit for now building. 13 EXPRESS 0 PLANNINQ PLANREVIEW Commercial BI(Igs; Provide -a completed Hazardous Materials Disclosure ❑ STANDARD 0 Putoxwonws Form if any Hazardous Materials are being used as part ofthis project. Q LARGIR 0 FIREARPT _Copy of Planning Approval Letter or Meeting with Plann ing prior to M,irrR El SANITARY sr vrRarlrrrmcT submittal of Building Permit appliontion. L.� F,NVrRJNMENTAI.nn,%rfru G'ldg[)I) 2011.docrei,i.ve(l76f21111