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13030148CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19400 STEVENS CREEK BLVD CONTRACTOR: ALL BAY PERMIT NO: 13030148 CONTRACTORS, INC. OWNER'S NAME: YUKO MIYOKO TRUSTEE 43233 OSGOOD RD DATE ISSUED: 03/28/2013 OWNER'S PHONE: 4085560200 FREMONT, CA 94539 PHONE NO: (650)298-0577 INCLICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL II Lic. # T. I. FOR INTERIOR DEMO & AREA UPGRADE TO License Class INCLUDE Contractor Date 13 MECHANICAL, ELECTRICAL & PLUMBING. INSTALL (N) I hereby affirm that I am licensed under the provisions of Chapter 9 PARTITION WALLS TO RECONFIGURE OFFICE SPACE (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. REVISION #I- RELOCATE EXISTING LIGHTS- ISSD OTC 4/25/2013 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $131379 I have and will maintain Worker's Compensation Insurance, as provided for by N Number: 37501023.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which permit is issued. APPLICA�staiufbrtnation I certify that I have read this applicis PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all state laws relating WI 80 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 DA OM LAST CALLED INSP CT ON. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Issued b Z Y Date: granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulati per the Cupertino Municipal Code, Section RE -ROOFS: 9.18. d Signature Date (� 5 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 -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 1, 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 M'p Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health &Safety Code, Secti 25505, 2r1r;1M1j25 34. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date-VxA permit is issued. 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 CONSTRUCTION LENDING AGENCY 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 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 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19400 STEVENS CREEK BLVD CONTRACTOR: ALL BAY PERMIT NO: 13030148 CONTRACTORS, INC. OWNER'S NAME: YUKO MIYOKO TRUSTEE 43233 OSGOOD RD DATE ISSUED: 03/28/2013 OWNER'S PHONE: 4085560200 FREMONT, CA 94539 PHONE NO: (650)298-0577 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL 11 q(,4 5r1S T. I. FOR INTERIOR DEMO & AREA UPGRADE TO License Class Lic. # Contractor Date `� �5 L3 INCLUDE MECHANICAL, ELECTRICAL & PLUMBING. INSTALL (N) I hereby affirm tha Iam licensed under the provisions of Chapter 9 PARTITION WALLS TO RECONFIGURE OFFICE SPACE (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. DEFERRED#1- INSERTED ENERGY FORMS-ISSD OTC 4/25/2013 I hereby affirm under penalty of perjury one of the following two il�clarations: I have and will maintain a certificate of consent to self-insure forWorkeks Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued..5wFt Floor Area: Valuation: $131379 I have and will maintain Worker's Compensation Insu provided for by APN Number: 37501023.00 Occupancy Type: Section 3700 of the Labor Code, for the perfo a work for whic O permit is issued. APPLICANT CERTIFICA'Arm I certify that I have read this application and state iDlKe 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 WITHINA 80 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 DA F M LAST CALLED INSP CTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Issued by: Date: �3 granting of this permit. Additionally, the applicant understands and will comply with all non-point source regula ' per a Cupertino Municipal Code, Section RE-ROOFS: If is 9.18. � Z� )3 Signature Date All roofs shall be inspected prior to any roofing material being installed. a roof 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) 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 Munic'Pq Code, Chapter 9.12 and 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 the Health & Safety Code, Sectio 25505,271, nd 534. Date: Lt 1 Owner or authorized agent: permit is issued. 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 CONSTRUCTION LENDING AGENCY 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 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 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19400 STEVENS CREEK BLVD CONTRACTOR: ALL BAY PERMIT NO: 13030148 CONTRACTORS, INC. OWNER'S NAME: YUKO MIYOKO TRUSTEE 43233 OSGOOD RD DATE ISSUED: 03/28/2013 OWNER'S PHONE: 4085560200 FREMONT, CA 94539 PHONE NO: (650)298-0577 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL 11 License Class Lic. # Fi(o LWIS j T. I. FOR INTERIOR DEMO & AREA UPGRADE TO INCLUDE Contractor Date 3 Z �3 MECHANICAL, ELECTRICAL & PLUMBING. INSTALL (N) I hereby affirm that I am licensed under the provisions of Chapter 9 PARTITION WALLS TO RECONFIGURE OFFICE SPACE (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: $131379 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: 37501023.00 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 WITHIN 180 DAYSRMIT 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 ST 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 ed by: Date: 7i granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section OeL RE -ROOFS: 9.18. Signature Date 3 ? 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 -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, Section 25505, 25533, 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. 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 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 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(ftupertino.org n r- I ill 4P 0 nnrr-THAT PPPKATT!! LJ NEW CONSTRUCTION LJ AUUIIIU14 u hiinic iiv" i i - - PROJECT ADDRESS +)o 5r1 Jp� APN # OWNER NAMEPHONE �� / _C E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS - CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME C{7 � (tAG LI E SE NUMBt '►► LICE TYPE BUS. LIC # COMPANY N44& aWoE-MAIL FAX STREET ADDRESS CITY, STA -M ZIP 4 c q ('A V J v PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE 1 DESCRIPTION OF WORK EXISTING USE - PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ FT. VALUATION (S) EXISTG AREA NEW FLOOR AREA DEMO AREA TOTAL NET AREA BATHROOM REMODEL AREA - KITCHEN REMODEL AREA OTHER REMODEL AREA .PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH 9DWELLINGUNCFS: " ISA -SECOND UNIT ❑YES SECONDSTORY ❑YES - - BEING ADDED? [3 NO ADDITION? [:]NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES-r LI VED BY: TOTAL V ATI N: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO i 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 t e Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws rel In to buil onstruction. ut ize a resentatives of Cupertino to enter the above -i eentii a property for inspection purposes. Signature of Applicant/Agent Date: �j /// _T/ SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROTITING SLIP OVER-THE-COUNTER BUILDING PLAN REVIEW New SFD or Multifamily dwellings: Apply for demolition permit for building existing building(s).. Demolition permit is required prior to issuance of / permit for new building. ❑ EXPRESS - ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS _ form if any Hazardous Materials are being used as part of this project. ❑ L ARGF ❑ FIRE DEPT Copy Of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT _ submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 Ldoc revised 06/21/11 CONSTRUCTION PERMIT APPLICATION �\ COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION .12 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buiidingCcDcupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION/ DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 1� 2 APN # i O / 0 Z-2, 3 OWNERNAME (/// //y0j0 7W(/ � O�7J PHO 58)S -SIE DU -MAL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME STREET ADDRESS J�� LL ' �/f CITY, STATE, ZIP FFAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT IVARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME /t/)n/_S CENSE NUMBER 7/O/J LICENSE TYPE BUS. LIC # COMPANY NAME' E-MAIL A}c�rfl.n STREET ADDRESS,4ai� 7T��i�'' CITY, STATE, ZIP �r � PHONE40 ARCHITECT/ENGINEER Nv W,!50d LICENSE NUMBER i � �) BUS. LIICCC##✓✓cci GJ COMPANY NAME /�A t ,] !�-�!tr , `_ - E-MAIL 't- I J,�✓�� FAX STREET ADD ✓ CITY, STATE, ZI'�� P ONE✓v, / 419 DESCRIPTION OF WORK /^ r EXISTING USE �f PROPOSED USE CONSTR I/ TYPE [i# STORIES /y USE TYPE OCC. SQ.FT. VALUATIONEXIS($) ARE T� i - AREA NEW FLOOR� AREA �_. /Jh OTAL INET AREA Imo/ V / / BATHROOM REMODEL ARE/ KITCHEN REMODEL AREA / OTHER REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH []ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ❑ NO ADDITION? []NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO VED B AL VALUATIO 1 By my signature below, I certify to each of the following: I am the property owne or authorized agent to act on the erty owner's behalf. I havg read this application and the information I have provided is correct. I have read the Description of Work and verify it is acc e. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identi ed property for inspection purposes. Signature of Applicant/Agf-r� Date: ��/ SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP El OVER-THE-COUNTER CJBUILDING 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 El STANDARD 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 ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO WN FEE ESTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: ADDRESS: 19400 STEVENS CREEK BLVD # DATE: 03/27/2013 REVIEWED BY: MELISSA PC FEE ID APN: 375 01 023 BP#: 0 3Q� 'VALUATION: $131,379 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement --7PERMIT PRIMARY Commercial Building USE: PENTAMATION 1 B TI TYPE: WORK T. I. FOR INTERIOR DEMO & AREA UPGRADE SCOPE PME Plan Check: OCCUPANCY TYPE: I TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) : II-B,111-B,IV,V-B 6,332 $2,332.16 1BTIPLNCK $4,855.96 IBTIINSP $0.00 PME Plan Check: $0.00 Permit Fee: $4,855.96 Suppl. Insp. Fee -.0 Reg. 0 OT F0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 6,332 $2,332.16 Construction Tczv: 1 $4,855.96 MECH, HOURLY 0 Yes 0 No PLUMB, HOURLY 0 Yes Q No ELEC, HOURLY 0 Yes (D No MISC ITEMS Plumb. i' Plan Check Fee: Other Alech. Imp. thher Plumb Insp. Usher Elec. Insp. Li 11" h bl"'). I'c' Mmlh. hlsp. FBS. I`", 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 nreliminary information available and are onlv an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 a 711,,"12) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,332.16 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $4,855.96 Suppl. Insp. Fee -.0 Reg. 0 OT F0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tczv: Administrative .Fee: 0 E) Work Without Permit? 0 Yes Q 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 $27.59 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $6.00 SUBTOTALS: $7,221.71 $0.00 TOTAL FEE: $7,221.71 Revised: 01/01/2013 INSTALLATION CERTIFICATE (Page 1 of 2) LTG-INST PROJECT NAME: / j ge. (l Q -c' � Y t (l C( Wl C q 1 DATE: 2 ✓ ✓ — I Building Permit PROJECT ADDRESS: Vj Applicable Sheets or Pages, Tables, Schedules, etc. Checked by/DateOLLI V0 Enforcement AgencyUse GENERAL INFORMATION DATE OF B�U' ILDI G POERMIT 1211 PERMIT # 3D I U 1 13030 BUILDING TYPE Nonresidential ❑ High -Rise, Residential ❑ Hotel/Motel Guest Room PHASE OF CONSTRUCTION ❑New Construction ❑Addition Alteration ❑ Unconditioned If more than one person has responsibilityfor building construction, each person shall prepare and sign an Installation Certificate document applicable to the portion of construction for which they are respo Iternatively, the person with chief responsibilityfor construction shall prepare and sign the Installation Certificatet fo he entire construction. DECLARATION STATEMENT • • I certify under penalty of perjury, under the laws of the State of California, the information prov d o orm is true and correct. • I am eligible under Division 3 of the Business and Professions Code to accept responsibility, for construc ion, or an authorized representative of the person responsible for construction (responsible person). • I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation) conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the enforcement agency. • I reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements for the installation. I certify that the requirements detailed on the Certificate of Compliance that apply to the installation have been met. • I will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: f� (l (�a � o,n� CO3zJ0C 5- Tr'r. or e 0c0.1(13 Responsible Person's Name: favi (vj D��'Ca� o Responsible on's $ig atu e: Lic.# 5 Date Signed: 5-3-13 Position With Company: , 1= lc cl $'1 rm � Iti Gl�q c SCOPE OF RESPONSIBILITY I Enter the date of approval by enforcement agency of the Certificate of Compliance that provides Date: the specifications for the energy efficiency measures for the scope of responsibility for this Installation Certificate: In the table below identify all applicable construction documents that speck the requirements for the scope of res onsibilit or this Installation Certi :tate. Date Approved By Document Title or Description Applicable Sheets or Pages, Tables, Schedules, etc. the Enforcement Agency C..�r� � �y��rC`yc: 2008 Nonresidential Compliance Forms August 2009 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: PERMIT # 01 Y6 OWNER'S NAME: PHONE # GENERAL CONTRACTOR: n,C _ BUSINESS LICENSE # ADDRESS: '432-33 CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) 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 Signature 3�za/f3 Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting 5,,, 3 Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Signature 3�za/f3 Date