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15080027CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15080027 10787 S BLANEY AVE CUPERTINO CA 95014 (369 34 053) D & L CONSTRUCTION OWNER'S NAME: LLC PACIFIC RIM PARK DATE ISSUED: 01/05/2016 OWNER'S PHONE: 408-203-8169 PHONE NO: 408-828-7947 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic. #903356 Contractor D & L CONSTRUCTION Date 02/24/2016 — BLDG —ELECT —PLUMB MECH RESIDENTIAL 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: TI - "MONSTER BOBA" TEA SHOP (1370 S.F.) I hereby affirm under penalty of perjury one of the following two declarations: RECONFIGURE (E) OFFICE SPACE AND CREATE (N) TEA t. I have and will maintain a certificate of consent to self -insure for Worker's SHOP WITH NEW WALLS, FLOORS, KITCHEN, EATING AREA Compensation, as provided for by Section 3700 of the Labor Code, for the AND MEP performance of the work for which this permit is issued. REV # 1 - REVISE DUCT WORK & REMOVE T -BAR @ DINING AREA - I have and will maintain Worker's Compensation Insurance, as provided for ISSUED 2/24/16 by Section 3700 of the Labor Code, for the performance of the work for which Sq. Ft Floor Area: Valuation: $82000.00 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 APN Number: Occupancy Type: ordinances and state laws relating to building construction, and hereby 369 34 053 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 PERMIT EXPIRES IF WORK IS NOT STARTED expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal 180 DAYS FROM JAST CTION. Code, Section 9.18. Issued by Signature Date 02/24/2016 Date: 02/24/2016 OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: installed without fust obtaining an inspection, I agree to remove all new materials for t. I, as owner of the property, or my employees with wages as their sole inspection. compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: z. I, as owner of the property, am exclusively contracting with licensed Date: 02/24/2016 contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the 2. I have and will maintain Worker's Compensation Insurance, as provided for California Health & Safety Code, Sections 25505, 25533, and 25534. I will by Section 3700 of the Labor Code, for the performance of the work for which maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the this permit is issued. Health & Safety Code, Section 25532(a) should I store or handle hazardous 3. I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25 33, and 25534. 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 Owner or authorized agent: be deemed revoked. Date: 02/24/2016 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lenders Name to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lenders Address judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant ARCHITECT'S DECLARATION understands and will comply with all non -point source regulations per the I understand my plans shall be used as public records. Cupertino Municipal Code, Section 9.18. Licensed Signature Date 02/24/2016 Professional Mi CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10787 S BLANEY AVE CONTRACTOR: CYB CONSTRUCTION PERMIT NO: 15080027 INC OWNER'S NAME: PACIFIC RIM PARK, LLC 43208 CONTINENTAL DR DATE ISSUED: 01/05/2016 OWNER'S PHONE: 4082038169 FREMONT, CA 94538 PHONE NO: (510) 857-3882 G� LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E] License Class_ Lic. # �i 4(- (6 TI - "MONSTER BOBA" TEA SHOP (1370 S.F.) RECONFIGURE (E) OFFICE SPACE AND CREATE (N) TEA r up �� n Date 1 / s�>01b Contractor Ci e COO ds C SHOP WITH NEW WALLS, FLOORS, KITCHEN, EATING AREA 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: $82000 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: 36934053.00 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 -jQLERMIT 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 sa DAYS FRO T CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgme s, costs, and expenses which may accrue against said City in consequence of the Issued by - granting of this permit. Additionally, the applicant understands and will comply with all non-po�sourcetions per the Cupertino Municipal Code, Section 9.18. Signature �� Date (�� / 2:91 OOFS: All roofs shall be inspected p nor to any roRE-Rofing material being installed. If a 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) 1, 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 1 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 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 255 5533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this —�� Owner or authorized agent Date: permit is issued. 1 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, 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 FM_7 CITYOF CUPERTINO 1� FEE ESTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: ADDRESS: 10787 S. BLANEY AVE DATE: 08/04/2015 REVIEWED BY: PAUL PC FEE ID APN: 369 34 053 BP#: 'VALUATION: 1$82,000 APERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: 1BTIPLNCK PENTAMATION 1 B TI PERMIT TYPE: WORK TI - "MONSTER BOBA" Tea Shop 1370 SJ. Reconfigure E offices ace and create N tea shop SCOPE with new walls, floors, kitchen, eating area and MEP OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,III-B,IV,V-B 1,370 $2,154.86 1BTIPLNCK $1,339.96 IBTIINSP Llec. k-' Fete. PME Plan Check: $0.00 Permit Fee: $1,339.96 Suppl. Insp. Fee -.0 Reg. 0 OT 10701 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 1,370 $2,154.86 Construction Tar:T-1 $1,339.96 MECH, HOURLY 0 Yes O No PLUMB, HOURLY ® Yes 0 No ELEC, HOURLY 0 Yes 0 No MISC ITEMS 111runh. Plan Cheri, Plan Check Fee: Phnnh_ other Mech. ln.sp r)rher Plumb InspLi other Elec. Insh. t! r.r; htsp. Hee,: /'/urnh. Insp. VC Llec. k-' Fete. 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 preliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (free Resolution 11-053 Eft. 711!13,) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,154.86 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. 0 OT FO.OThrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,339.96 Suppl. Insp. Fee -.0 Reg. 0 OT 10701 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tar:T-1 I (Irnntrstratrrtr FcF - 0 G Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 0 i Travel Documentation Fees: Strong Motion Fee: IBSEISMICO $22.96 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $4.00 SUBTOTALS: $3,521.78 $0.00 TOTAL FEE: $3,521.78 Revised: 07/02/2015 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15080027 10787 S BLANEYAVE (369 34 053) 43208 CONTINENTAL DR FREMONT, CA 94538 OWNER'S NAME: LLC PACIFIC RIM PARK DATE ISSUED: 01/05/2016 OWNER'S PHONE: PHONE NO: None LICENSED D ONT A TOR'S DECLARATION BUILDING PERMIT INFO: License Class CONTRACTOR - GENERAL Lic. # Contractor Date 01/31/2017 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: t, 1 have and will maintain a certificate of consent to self -insure for Worker's 2. —BLDG —ELECT —PLUMB _ MECH _ RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: TI - "MONSTER BOBA" TEA SHOP (1370 S.F.) RECONFIGURE (E) OFFICE SPACE AND CREATE (1) TEA SHOP WITH NEW WALLS, FLOORS, KITCHEN, EATING AREA Compensation, as provided for by Section 3700 of the Labor Code, for the AND MEP performance of the work for which this permit is issued.REV # 1 - REVISE DUCT WORK & REMOVE T BAR @ DINING AREA I have and will maintain Worker's Compensation Insurance, as provided for by - ISSUED 2/24/16 Section 3700 of the Labor Code, for the performance of the work for which this REV #2 - REVISE STRUCTURAL CONNECTION FOR TRASH 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 regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 6 r 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. 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. ENCLOSURE REV # 3 - REVISE SEAT LAYOUT. ISSUED 6/13/16 Sq. Ft Floor Area: I Valuation: $82000.00 APN Number: Occupancy Type: 369 34 053 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: 01/05/201 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 & Safety Code,�d25505,255 , and 25534. Owner or,autho 'zed agent: Date: /� `/ !0 INSTRUCTION LENDING=AGENCY I hereby affirm 1hat 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 Signature Date I understand my plans shall be used as public records. �C--IUPERTINO I 1 mrxxl rnATCTD I rr TTnAT CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingacupertino.org # ❑ ADDITION ❑ ALTERATION / TI REVISION /DEFERRED ORIGINAL PERMIT # �y 17 �� D PROJECT ADDRESS ( 1 c./ JL- APN # OWNER NAME �O} h,u i LA PHONE , LO �a 03 -816 9 p E-MAIL / % �I / C (�/' 91714 r� • (O J an J STREET ADDRESS n D n �� `1 D� OW 1LG�A` CITY, STATE, (��� os A �� S� /T FAX CONTACT NAME -0 GQ -a 03 _8 161( PHONE 4-09-2 '7"0 E-MAIL C tI . (►y Y .�4 yh.lqI l (ct>7 STREET ADDRESS a660 n u ctD) P 1 n r CITY, STATE, ZIP'34.4, oS e Ch q ; FA\ 1 w OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME K�Lvin 'Do " LICENSE NUMBER � 0 b b LIC ENSE TYPE 66 BUS. LIC # COMPANY NAME L e, E-MAIL FAX STREET ADDRES CITY TATE, ZIP PHONE ARCHrrECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK _ V� S 2 S-fYu.c,+ravl C o h n e C,•i-i a h � r 'IT0..8 � G 1 Uc t 1; L.:+�r' __ EXISTING USE PROPOSED USE CONSTR. TYPE. I # STORIES OFFICE USE ONLY OCC TYPE DE RIPTI N SOFT. VALUATION EXISTG NEW FLOOR TDEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑ DETACH ❑ ATTACH - DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEINGADDED? ❑ NO ADDITION? ❑ NO PRE -APPLICATION ❑ YES IF YES PROVIDE COPY OFPLANNER'SNAME: RECEIVED BY: TOTAL VALUATION. PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER 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 to building cons n. I orize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ElSTANDARD El PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ ❑ submittal of Building Permit application. MAJOR SANITARY SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH BIdgApp_M L doc revised 03116111 CUPERTINO 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: I D%$ 7 S 614r) tj Ave C u e vti l) 0 PERMIT # ISO 8-oo a OWNER'S NAME: S hu U n 0 u PHONE # U o ff-'203- 916 9 GENERAL CONTRACTOR: p b, L CONS v u d1 o n BUSINESS LICENSE # 3 4 g q ADDRESS: 3 Al V-CI- mi) i on c.r+. CITY/ZIPCODE: S 4 os e q15 3 5 *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: 6 6 Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DMS 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255. (408) 777-3228 • FAX (408) 777-3333 • buildingCcDcupertino.org CUPERTINO n NFW rn\,gTRI It TTON n ADDITION n .ALTERATION / TI �VisiEFERRED ORIGINAL PERMIT # 1 07PROJECT ADDRESS L, q ,l q S_ g i a n-eL A v g APN # 3 L- 9_ 2 o5_ C/ OWNER NAME 1/ I I U 03- C I t 9 E-MAIL PHONE( 1 1 ©� ' Z03 - b I I STREET ADDRESS J O I 0 11 rj I a n v l 0 R CITY, STATE, ZIP Cu -eY4ino 6:q gSUIL- FAX CONTACT NAME1 � Wend h VU PHONE �) �Dn w -end a FGuSa�g- CC)rn +OF _ q a O �j STREET ADDRESS a o n ot^r e D CITY, STATE ZIP raA o e q513 FAX 40 - 1-q9,0 ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME N LICENSE NUMBER(qo LICENSE TYPE BUS. LIC # t� COMPANY NAME, E-MAIL FAX STREET ADDRESS CITY STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-NiAAlL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF IA'ORK 1✓(ON 7� t—^Pr_—HAr--�tcAA_ L)CT EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODELAREA REMODELAREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJ DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY E3 YES BEING ADDED? ❑NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES TOT VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? By my signature below, I certify to each of the following: I am the property owner or authoriz _ent t9,a o 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 ve .I is accurate. I agree to comply with all applicable local ordinances and state laws relating to building con ruction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: l SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ ❑ New SFD or Multifamily dwellings: 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. ❑ E.XTRESs ❑ PL4NNING PLAN REVIEW)' _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC NYORKS form if any Hazardous Materials are being used as part of this project. ❑ ❑ LARGE` FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to V ❑ tiLA loR ❑ SANITARY submittal of Building Permit application. SEWER DlsrxlcT ❑ ESVIRO\17ENT.AL HEALTH Blde 4pp_2011.doc revised 06/21/11 CUPERTINO CONSTRUCTIONI PERMIT APPLICATION COMMUNITY DEVELOPMNT DEPARTMENT • BUILDING DIVISION ell 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408),777-3333 • building(5_)cugertino.org V n NF.w cONSTRi tcT'ION n ADDITION F� ALTERATION / TI ILSIVI N / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS / Q W 7 J yh Ave, j APN # OWNER NAME I PHONE �g _� �j _ Q (G J c7 0 E-MA1L 11(Aq 0 02,J (;,� Q1 J - C 011'I lJ STREET ADDRESS STATE, ZIP FAX 12,ACITY, 0 9 CONTACT NAME VIA( PHONEE-MAIL 3 — I C rt4 OOdA L hKoul • [o" STREET ADDRESS CITY STATE FAX b ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER TENANT CONTRACTOR NAME . NUMBER 103366 LICENSE TYPE BUS. LIC # N Q `LICENSE COMPANY NAME L Co ✓IS t -N o n E-MAIL 6 n.tow • to w. FAX STREET ADDRESS ' _ CrrY, STAT ZIP PHO _ - 721,42 ARCHITECT/ENGINEER NAME I ICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK R av I r` F6 IL t _(4— EXISTING USE PROPOSED USE CONSTR E I *STORIES USE 7YPE. OCC. SQ.F'f. VALUATION ($) EXISTG AREA NEW FLOOR AREA DEMO AREA 70TAL NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODELAREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJDETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? []NO •PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEI TOTAL VA PLANNING APPL# ANO PLANNING APPROVAL LETTER EICHLER HOME? [J NO By my signature below, I certify to each of the following:, I am the property owner or authorized age t act on e property owner's behalf. I have read this ork and ve urate. I agree to comply with all applicable local application and the information I have provided is corre t. I have read the Description of' itis ordinances and state laws relating to building constru t' n. u rize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMA I N REQUIRED �' PLAN CHECK TYPE ROOTING SLIP ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Trovide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. E) LARGE El FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to El MAJOR El SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06121/11 I- Z14 CUPERTINO- ❑ NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION 66 wmt COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (4 8) 777-3333 • buildingCcDcupertino.org ❑ ADDITION . ❑ TERATION / TI ❑ REVISION / DEFERRED ORIGINAL PFRVTT PROJECT ADDRESS 079 I __7 APN9 20 E-MAIL OWNERNANS Ila PHONE6,�5 2 I i, STREET ADDRESS 'J 0 CITY, STATE, ZIP F X 78 CONTACT NAME J PHONE 09 STREET ADDRESSQ CITY, STATE, ZIP Tose,r3 F. -,X 13 OWNER ❑. OWNER -BUILDER ❑ OWNIERAGENT 13C NIRACTOR ElCONTRACTOR AGENT eARCHITECT ❑ ENGA'EER ❑ DEVELOPER ❑ TENA1 T CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC k COMPANY NANIE E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME S � LICENSE NUMBER � BUS. LIC R ! COMPANY NAME /' • E-MAIL FAX - N STREET ADDRESS - Pr CITY, STATE ZIP �? PHONE(;zywxffP- `q q DESCRIPTION OF WORK � r EXISTING USE PROPOSED USE CONSTR. TYPE 4 STORIES 1 11 USE TYPE OCC. SQ.FT. VALUATION (S) E,CST ARF AREA A NEV FLOOR DEMO AREA AREA -� TOTAL NET AREA ` , ^ 11� - ,v 1,370 Y JKJ BATHROOM KITCHEN OTHEF REMODEL AREA REMODEL AREA REMODEL AREA PORCHAREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: LJ DETACH I 0 ATTACH DWELLINGURffS-. IS A SECOND UNIT ❑YES SEC ND STORY ❑YES ` BEING ADDED? ONO =STORY NO I PRE -APPLICATION ❑ YES IFYES, PROVIDE COPY OF PLANND4GAPPLR [-]NO PLANNING APPROVAL LETTER IS THE BLDG AN E] YES EICHLERHOME? ❑NO - IVED.BI TOT VALUATION: �a - - - m a 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 hav read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building con ruction. I t Drize representatives 'of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: C+�a SUPPLEMENTAL INFORMATI UIRE RE D Q � :rz.'PLAt�,GHECK�Y�EI' ` . p Q3IIJgSL'_I' New SFD or Multifamily dvv,ellings: Apply for demolition permit for ��,� X existing building(s). Demolition permit is required prior to issuance of building35 OS ERTH QOUhTER �� BUILDING` z permit for new building. 5 '�� � - z = WG PK ELe1Tr: Commercial Bldgs: Provide a completed Hazardous Materials Disclosure NEWS� _ NEWSK-�• - xa• ©s�A r,rteRDC]�PTra tx _ form if any Hazardous Materials are being used as part of this project. �o 0L�w t. Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. M:470R�SATTI'.ARYSEi� - -- �-� RDIST' O._ on-MENr�.x=AVTa��=� BIdk4pp_2011.doc revised 06121/11 CUPERTINO APPLICATION FOR CERTIFICATE OF OCCUPANCY OR CERTIFICATE OF COMPLETION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(cDcupertino.org COMPT.RTF, A SFPARATF, APPT.TCATTON FOR FACTT RTTTT.I)TNCT- PROJECT ADDRESS • n 1 Q l o (` I^j J 9 �' e V APN # l DATE a ao 16 OWNER NAME Shugn u" 2 PHONE IA -0 03- 9 f-91li E-MAIL U goo -2A O M6 STREET ADDRESS Q- 0 CITY, STATE, ZIP 2an b)ae FAX CONTRACTOR NAME uglu cpy)�i-VtAciio) Ur' PHONE-0 HONE - I 82 1 US E-MAIL STREET ADDRESS 1 y - CITY, STATE, ZIP uS' FAX ✓TAIL CERTIFICATE TO: (Please allow up to 10 business days for delivery): CONTACT NAME PHONE E-MAIL -Hons+P-,r (jim D 8 -ao - I I-qoddma4.(cry, STREET ADDRE S CITY, STATE, ZIP FAX 107 S, q�0 LIST ALL BUILDING PERMITS ISSUED FOR PROJECT: OCCUPANCY DATA: USE OCCUPANCY TYPE FLOOR AREA OCCUPANT LOAD 1 2 3 4 BUILDING DATA: # STORIES BELOW GRADE PERMIT NUMBER SUBMIT ISSUE DATE DATE DATE INSPECTOR SCOPE FINALED l ISO 0*1 d (05 ' 6 06 zll( v v 2 — 3 OCCUPANCY DATA: USE OCCUPANCY TYPE FLOOR AREA OCCUPANT LOAD 1 2 3 4 BUILDING DATA: # STORIES BELOW GRADE # STORIES ABOVE GRADE OVERALL FLOOR AREA MAX OCCUPANT LOAD FIRE SPRINKLERS REQUIRED (YES OR NO) FIRE SPRINKLERS PROVIDED ES OR NO # PARKING REQUIRED # STANDARD/COMPACT PARKING PROVIDED # ACCESSIBLE PARKING PROVIDED NOTE: ATTACH A COPY OF THE SIGNED INSPECTION CARD TO THIS APPLICATION. - OFFICE USE ONLY - SPECIAL STIPULATIONS OR CONDITIONS: CHECKLIST: Copy of Job Card Attached (both sides)? Pennit Signed off in system? No other pennits open or expired in system? Location of Approved Office Set? CofO Application. doc revised 05/17/16 CITY OF CUPERTINO BUILDING PERMIT INSPECTION CARD BUILDING ADDRESS: 10787 S BLANEY AVE CONTR-4,C'TOR. CYB CONSTRUCTION }'ER;VM NO: 15080027 INC: OWNERS NAME: PACIFIC RIM PARK, LLC 3208 CONTINENTAL DR DATE ISSUED: 01/05/2016 OWN"E',R.'S PHONE -. 4082038169 FREMONT, CA 94538 ( PHONE NO: (510'1857-3882 i7' )UNDA'ri ON/PI- RS %II.D. S. UR GROUND "AUrST'T R AL k (EP.'I , '€GARr art S.L.\F3 /FRE(iJN11'E n(?] )k ? t'L1'yr'I �'Ti i3\TI1 �SBCIYF, I:L4S BEEN'.-SIG3SEI3 `;1 jN E 6RO' ND SLA'3 f x s UNDERG::OUND PLI MBING 117)PRGn0Ur41) '.rRICAL� �On NO T YJt ]t fri L?( R C NTII ''Bowl Il$EE1\, SIGNED UNDERET COR PL IM13MG UNDERFLOOR MECHANICAL t UND) RF) OOR ELECTRICAL UNDERFLOOR FRAMING VENTS f UNDERFLOOR INSULATION PL4C7 NQ--StiI3hI,t701ci}h CII;4B>1i,EM- AEEIYSI(;t`ED F UCH'I.t.JTvIR)*1 3S C ) i0WI R P AN �Zt7 rII MhCT 1NIC.AL C- � ti :�(:IgCiH ELLC''l21(�.AL.P rel `i[T' 'D 3,& 1.?A91?v�,'S'>.�)RS!E IIiREE��wt�3 a 1, P EIV(YV1.vt31�k€ N I .ABf} i E II IK;BI) lit SlSrl\ER „. -Y q EX iL•R OR SHFA.LIiO1 D DOWN' tT'F IORSia ARrT)1DDOWN�� § �� N5?I1FfRVCriJ E+r 1':OCKSHF s EX .2gOr. i. , r.-1.'CReLDD i _ t 1UN'irltl} In111 riiF) T::P t17 FIx LS �fRah Tlt 111('11 SIA IiT 1 ii SIT.NEir sTr= sC.RA fC11 COA1 1 t' S •:WER r WATE R -B( RA : CH } Ll C ABOVE CELL 7'r ELE t GAS I t I�T' I, l E IR Lam- iASi: I GRAD °UFl l W:)RKS ) �i1R'~ Ai.l (408) 8.:.01 -j �•\��`�� +rfC r � ELL( T"I Ri- AL IVI1�iIANIC.4) j PI,U AI IVIG W 1:ANDiCAP ��� �Flu�� � 1 N} (r Y F iJl1 JP�G C41-4 ��ER I lE76 OF OLu 1 4Ni Y ` , BUILDING PERMIT INFO: BLDG ELECT' PLU1NIB MECH RESIDENTIAL f. COMMERCIAL JOB DESCRIPTION: TI - "I1ONS-2 P. BOBA" TEA SHOP (1370 S.F,) RECONFIGURE (E) OFFICE SPACE AND CREATE (N) TEA SHOP WITH NEW WALLS, FLOORS, KI'T'CHEN, EATING AREA IWILDLAND URBAN INTERFACE FIRE .AREA r, ER# TO ARRANGE INSPECTION Call 777-3228 between 7:30 am and 3:30 pm Monday through Friday, at least 24 hours before required inspection. Job address and Permit Numbers are needed when requesting ar. inspection. CUPERTINO SANITARY DISTRICT Closed circuit video inspection of property line cleanout, point of connection and street lateral required prior to passing FINAL CITY PLUMBING INSPECTION. Call the District (408-253-7071) for an appointment. NO BUILDING FINALS INSPECTION'S UNTIL: ALL BUSINESS LICENSES ARE OBTAINED PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LASTC.JkLL ED INSPECTION. IMPORTANT When a permit has expired, a charge totaiing one-half the fees to obtain a new permit must be pair] in order to reactivate the permit. If a permit has been expired for more than one year; a charge totaling the full fees to obtain a new permit must be paid r to reactivate tt%permit. wr,NDTES: f SPECIAL INSPECTIONS Inspector: _ 1)ate: ROOF INSPECTIONS PRF -INSPECTION: Inspector: TEAR -OFF: Inspector: PL.1 VOOD: Inspector: BATTENS: Inspector: IT, PROCIRESS Inspector: FINAL.: Inspector: Date: Date: _ Date: Date: . Date: _ Date NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION. t OCCUPANCY O? BUILDING NOTPERMITTED UN"CIL BUILDING FINAL. IS SIGNED BY y-i�--�� ��SG, ������ �Uw�'fv�, DIS c3�-- N Cmu VJAL Oir, I OV, -T JV,_ 440P40ZAgW-- fM -