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15040217El CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20955 STEVENS CREEK BLVD CONTRACTOR: BSM, INC PERMIT NO: 15040217 BUILDING SERVICES/SYSTEM OWNER'S NAME: WEISS PAUL E AND BARBARA H TRUSTEE 2575 STANWELL DR 2ND FL DATE ISSUED: 04/29/2015 OWNER'S PHONE: 5104287078 CONCORD, CA 94520 PHONE NO: (925) 688-1234 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INTO: BLDG ELECT PLUMB License Class Lic. # $-1 Ml r7 F MECH RESIDENTIAL COMMERCIAL Contractor 'uWIA- e0AI>tJUC t-ro>, Date 54_ *(5_ JOB DESCRIPTION: WHOLE FOODS -REMODEL (E) MEN'S & WOMEN'S RESTROOMS(415 S.F.) I hereby affirm that I am licensed under the provisions of Chapter 9 REVISION #I: REMOVE AND REPLACE SHEETROCK IN BATHROOMS. ISSUED (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force 5/13/15 and effect. I hereby affirm under penalty of perjury one of the following two declarations: OAT 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: $52000 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 permit is issued. APN Number: 32631022.00 Occupancy Type: 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 WITHIN 180 DAYS OF PERMIT 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 save 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by: Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. �— �' RE -ROOFS: Signature Date ('� 1 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. ❑ OWNER-41,13YR 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 I 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 I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have 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: Date: (3 SS I certify that in the performance of the work for which this permit is issued, I shall 0 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, 1 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 Lender's Address 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, ARCHITECT'S DECLARATION 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 CONSTRUCTION PERMIT APPLICA-hbW COMMUNITY DEVELOPMENT DEPARTMENT • BUILDINdl-D%1 1�1 10300 TORRE AVENUE • CUPERTINO. CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408) 777-3333 - build in cu ertino.or ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION /TI VISIO / DEFERRED ORIGINAL PERMIT # 1®21 7 PROJECT ADDRESS zoaf% �ua✓Hs C4,EFL/-- aUv� APN # �`2 Z 32� - 3+ OWNER NAME toe 'b kQL VJE1SS PHONEE-MATE 510 L1213 Zo- & MEC -4. SZUgsll)D C WHoc.FFe4 . Cwl STREET ADDRESS CITY, STATE, ZIP LuFt'Ym"o FAX f rM LJ u CONTACT NAME PHON�EE E-MAIL Me 0k S1 u L(Ztb ?OZ `o Q STREET ADDRESS CITY, STATE, ZIP FAX 5°l8o Mwp GT-. -ITE v e, 'tLM11 ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUM9 RLICENSETYPE BUS, LIC# ►tel bN U o C 9 5 Sys COMPANY NAME E-MAIL FAX �L ce s 6125- Atp 0 STREET ADDRESS CITY, STATE, ZIP arts 2� PH NE &2s Z w t �� tom 1? -3,4 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # T kO LA CO NAME E-MAIL FAX c IR P P,0 LA • c -w-. STREET ADDRESS CITY, STATE, ZIP , J PHONEISO FPJVt-2.1111 cSf lJ PC DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA _ BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK DECK/PORCH AREA GARAGE AREA: DETACH !7TOTAL ❑ATTACH # DWELLING UNITS: ND UNrr ❑ YES SECONDSTORY ❑ YES DED? []NO ADDITION? ❑NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN [:]YES RECEI D-RY '�-� --.- TOTAL VON: PLANNING APPL k ONO PLANNS7G APPROVAL LETTER EICHLER HOT1E? ❑ NO 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 bu ding construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: J� SUPPLEMENTA FORIvIATI UIRED115-1 k fsr t°' � { AW �PI AN CHECK TYPE k.: / ,. itOUTING:.SLIP. !�. p Y r1h O VER THE-COUNTETtr a r HUILDIlVG PLAN REVIEW New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building �r 4s4 i,a z t� 7�gs }rt permit for new building.Er 3" 7`.EZPiiE sFWENSzg ` rte' `" ❑,uFLANAING PLAN REVIE Yr Commercial Bldgs: Provide a completed Hazardous Materials Disclosure �#— DsrANnARDx z ❑PUBIIcwoRTCS, _ form if any Hazardous Materials are being used as part of this project. gym �r� A- rig LARGE, ` a� �� `� 3 ' k d ` rf. ZEN FIRE DEPTu Copy Planning Approval NN 3� t ss r of Letter or Meeting with Planning prior to 10 STiuci sgPermit application. ti �oR �zu_m �-Am �s�AllITARISEWERDIb w i ':.-. ��aENV1It01�MENTAAEA1TAk�$ _ BldgApp_201 Ldoc revised 06/21/11 CUPERTINO 1 I f I 1.T17Tz7 rr))1TeTDT1r-rTn1J CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • buildingP-cupertino.org AnnTTTnm IV ATTFRATTfTN/TT I I RFVTSTC)M/TIFFFRRFT) ORTCUNAT.PERMTT# PROJECT ADDRESS APN # 2 - 3 I J 2,7Z- 5S 5i e�� �-�>v � v� OWNER- E-MAIL n OWNER NAME t `1 PHONE -70-7P--, W ISS 4.2-b !-� 0 (7 .( CITY, STATE, ZIP FAX STREET ADDRESSS/� c Jl C�y O G Q�� �K-cis" �bW 4V� 1JG CONTACT NAME PHO E-MAIL (o ZOTa JJI�G •ST ? w ons - co►� STREET ADDRESS CITY, STATE, ZIP FAX O ST- 5 l-�E 2tL tEcam.Lyvut CES a ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CO CTORNAME LTCENSENUMBER LICENSETYPE BUS. LTC# M o C�5 3 COMPANY NAME E-MAIL 3—ECA {xS (—rj FAX qn l00 STREET ADDRESS OS -757 CITY, STATE, ZIP CA , C' SAS 2C) P `1 3 ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS. LTC # LD `jPPoUN M9PANY NAME C E-MAIL FAX _ P - L& _PP OLk CO}� STREET ADDRESS 11 ``(n� %f - - L "��%1T 1 T. t ' ff F CITY(, STATE, `ZIIPr r o p q/� SRIR Nc_k<k'Vl , �.i l -L" 1 � � � PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA f I S S21 V W BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKJPORCH AREA GARAGE AREA; DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? ❑NO PRE -APPLICATION ❑ YES IFYES, PROVIDE COPY OF IS THE BLDG AN ❑ YES • ,"� ;, - TOTAL VALUATION,: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO , � „ _ tr-�OO /) V max{ a J By my signature below, I certify to each of the following: I am the property owner or authorize agent to act on the 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 te. I agree to comply with all applicable local ordinances and state laws relating to building construction. I'authorize representatives of Cupertino to enter the property for inspection purposes. �ab/ove-identified Signature of Applicant/Agent: Date: 7%� 5 SUPPLEME14AL INFORMATit44 REQUIRED PI AN CHECK TYPE ._ N 5RO_ ING SLIP OVER TH)rCOTJNTER � `*� m 01 M171t9, PLAN REVIEW � New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of buildings r❑�BUII,DING e s. �• r permit for new building. 6 - Q'I.EZPRESSc f ❑ pI.ANIU.IGYIZEVIEW '` a Commercial Bldgs: Provide Hazardous Materials Disclosure RR ®siAxDAzzD �°❑ x�vBLTcwoRics,k _ a completed ti n 1 i form if any Hazardous Materials are being used as part of this project. i �� LARGE�`��i �`" ����, �❑ �IltEDEPTrx i, �� �,��'k!��E � Copy of Planning Approval Letter or Meeting with Planning prior toE ❑ submittal of Building Permit application. £©Mox sArTrARY sERBRpISTHICTT BldgApp_2011.doc revised 06/21/11 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 450.14-3255 Telephone: 408-777-3228 Fax: 408-777-3333 )OB ADDRESS: Z CR917 CR eK vD PERMIT # /50 `fDZI'7 OWNER'S NAME: W1 AOLE T-cc�[aS MARr� PHONE # q'25 GENERAL CONTRACTOR: BUSINESS LICENSE # Q Scocts ADDRESS: 2—S -IS; j,1�p,)�� CITY/ZIPCODE: . C,P\ *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: Signature Please check applicable subcontractors and complete the following information: Date ✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & M.il.lwork Cement Finishing Electrical ��,A 'bpWc--H eLeC:T?,ke. Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing our ► RE M��N 2 On Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date 'DNIINSH 00TT989S96 %V3 TV:OT STOZ/80/SO CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20955 STEVENS CREEK BLVD CONTRACTOR: BSM, INC BUILDING PERMIT NO: 15040217 SERVICES/SYSTEM OWNER'S NAME: WEISS PAUL E AND BARBARA H TRUSTEE 2575 STANWELL DR 2ND FL DATE ISSUED: 04/29/2015 OWNER'S PHONE: 5104287078 CONCORD, CA 94520 PHONE NO: (925) 688-1234 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ WHOLE FOODS - REMODEL (E) MEN'S & WOMEN'S License Class Lic. # RESTROOMS (415 S.F.) $u�e..��►kq Se*.w C&%/ y Contractor eSeN. Nfcty+tE>1 Date 12-a11 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: $52000 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: 32631022.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that l 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 WITHIN 180 DAYS OF PERMIT 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 save 180 DAYS FR LED INSPECTION. 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 Iss with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. 1 A- RE -ROOFS: Signature Date 2 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. ❑ 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) I, 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 I 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 I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections ;5505,25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this 4J/ Owner /1217 permit is issued. or authorized agent: Date: l l certify that in the performance of the work for which this permit is issued, l 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 l 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 CITY OF CUPERTINO FF.F. FSTIMATOR — BUILDING DIVISION kaADDRESS: 20955 STEVENS CREEK BLVD DATE: 04/29/2015 REVIEWED BY: MELISSA Plan Check Fee: APN: 326 31 022 BP#: EVALUATION: $52,000 71 *PERMIT TYPE: Building Permit 1 hrs PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: $0.00 PENTAMATION 1 M TI PERMIT TYPE: WORK WHOLE FOODS - REMODEL E MEN'S & WOMEN'S RESTROOMS 415 S.F. SCOPE hrs OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. S.f. M (Tenant Improvements) II-B,III-B,IV,V-B 415 $2,892.46 1MTIPLNCK $708.58 IMTIINSP I TOTALS: 415 $2,892.46 I ^i $708.58 F", 1-1 1. -P, 711, 1 c e N7.Li :.pia;? ("'Wok Fe": . irec;, 'ern 0,,_4_ NOTE: This estimate does not inchide fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). these tees are basea on the Prellminary information available ana are only an estimate. Contact the Dent for aaan't into. FEE ITEMS (Fee Resolution 11-053 F, f. 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,892.46 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Reg. 0 OT 1 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $708.58 Suppl. Insp. Feer Reg. OT0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 0 Work Without Permit? 0 Yes (F) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Q Building or Structure Strong Motion Fee: 1BSEISMICO $14.56 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $3.00 a SUBTOTALs? s.._ _.. ... _. ... ,. , ._ $3,618.60 $0.00 r TOTAL FEE: $3,618.60 Revised: 04/01/2015