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09090020CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19765 STEVENS CREEK BLVD CONTRACTOR: TBD - TO BE PERMIT NO: 09090020 DETERMINED OWNER'S NAME: JO -ANNE STORES CORP DATE ISSUED: 10/16/2009 OWNER'S PHONE: 3306562600 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONI— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # /} 61 r i— Contractor Date 1-1-2 `6 U MECH RESIDENTIAL COMMERCIAL 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: T.I 17,469 SQ FT INTERIOR STORE FIXTURE (commencing with Section 7000) of Division 3 of the Business & Professions RENOVATION/ RESET WITH SAME ELECTRICAL ENTRY Code and that my license is in full force and effect. DOOR RELOCATION. RESTROOM MODIFICATION FOR ADA WITH 1 hereby affirm under penalty of perjury one of the following two declarations: NEW 1 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: $60000 performance of the work for which this permit is issued. 1 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: 31620083.04 Occupancy Type: permit is issued. APPLICANT CERTIFICATION - I certify that Lhave ;ead this application and state that the aiove information is PERMIT EXPIRES IF WORK IS NOT STARTED torrent l agree to cc,mp!y with all city and county ordinance': and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above meniioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harnless the City of Cupertino against liabilities, judgments, costs. and expenses which may accnie against said City in consequence of the --. Issued 151- Date: /P.d K4, grar.iing of this permit. Additionally, the applicant understands and will comply with all non -point sowce regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signatures Date Z -Ir 0All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1, 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 prr)pe-.ty, or my employees with wages as 'heir sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as towner of the property, am exclusively contracting with 'icensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sc:c.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 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 1 store or handle hazardous 1 !lave 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 I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I bav,�. and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Owner or authorized agent:Ey Date: I certify that in the performance of the work for which this permit is issued, 1 shall not employ any persor, in any manner se as to become subject to the Worker's Compensation laws of California. If, after making this certi�icate 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 arch 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 ieW 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 constructicn. and hereby authorize representatives of this city to enter union the above mer.tirmed property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in cpnsequence 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 CITY OF CUPEkTINO CITY OF CUPERTINO TENANT IMPROVEMENT PERMIT APPLICATION FORM �AbOtCp20 AM,; # 31 Date: -- 3 Building Address: /9745 STr-toNS CQj!-�F-K 7F1,�? Mailing Address (if different from building address): Tenant ❑ (If tenan please provide a letter from the building owner approving the tenant improvement.) Building Owner` Are Hazardous Materials being used as part of this project? Yes ❑ No Tenant/Building Owner's Nam : hone #: 330 , (.05G r _Z� (060 VIM71 r=�N �I'�G C o -�N-rotre9 (0 Contractor: Phone #: Fax #: Contractor License #: Cupertino Business License #: Contact: LISA. (,t )VAV r -_e: AR eF1 1V Phone #: 330 g 1 l 12- 4� Arrouo'l9 kRBnr o# Fax #: 330 � 5 77-, T- (© 1 Alternate Co tact: Pt --44v12 Phone #: -330 , , GK Fax #: 330 „ Valuation (cost of proj ct): A Job Description (be specific): ' �a�� VC UdL>< � /kgT tu/77r ►-+`f sd� r Tenant Improvement Includes Re -Roof. Yes ❑ NkQIf yes, number of squares Tenant Improvement Includes Structural Yes ❑ No Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ IUIII/V-A ❑ IUIII B, IV -HT, V -B \C� Project Size: Express ❑ Standard © 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 07/06/09 100 V- - CITY OF CUPERTINO TENANT IMPROVEMENT ]FEE SCHEDULE Quantity. Fee ID Fee Description Fee Group. Permit Type 1 ATINSP Tenant Improvement B EAA TI' Inspection 1 ATIPLNCK Tenant Improvement Plan B Check 1BTIINSP Tenant improvement B 1B TI Inspection 1BTIPLNCK Tenant Improvement Plan B Check 1ETIINSP Tenant Improvement B 1E TI Inspection -Preschool 1 ETIPLNCK Tenant Improvement Plan 'B. Check -Preschool 1FTIINSP Tenant Improvement B 1F TI Ins ection-Factory/Indust 1 FTIPLNCK Tenant Improvement Plan B Check-Factory/Indust 1HTIINSP Tenant Improvement' ' ' B 1H TI Inspection -Hazardous 1HTIPLNCK Tenant Improvement Plan B Check -Hazardous IITIINSP Tenant Improvement B lI TI Inspection -Institutional IITIPLNCK Tenant Improvement Plan B Check -Institutional 1MTIINSP Tenant Improvement B 1M TI Inspection -Merchandise 1MTIPLNCK Tenant Improvement Plan B c16 q Check -Merchandise 1 STIINSP Tenant Improvement B 1S TI Inspection -Parking Garag 1 STIPLNCK Tenant Improvement Plan B Check -Parking Garage 1 REROOFCOM Re -Roof Commercial ; B 1BCBSC Cal Bldg Standards B ALL PERMIT 'TYPES Commission Fee 1BSEISMICO Seismic Commercial B c 1BUS LIC Business License B 2 of 2 CITY OF CUPERTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: �S� s►1 cry (TlUd. PERMIT # nF0 d OWNER'S NAME: , -rQ-S e PHONE #;3� e 51 S?. - 2 GENERAL CONTRACTOR: " Nio-- Coqfr FAX # I am not using any subcontractors: �kl (D /0-/ F ---0 -�, Signature Date PIease check applicable subcontractors and complete the following information: Owner/ Contractor Signature Date 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 Owner/ Contractor Signature Date