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14060107CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10100 MARY AVE CONTRACTOR: AVERY GLENBROOK LP PERMIT NO: 14060107 OWNER'S NAME: AVERY GLENBROOK LP 130 E DANA ST DATE ISSUED: 10/07/2014 ONN NER'S PHONE: 6505913050 MOUNTAIN VIEW, CA 94041-1508 PHONE NO: 0- LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL GLENBROOK APT -COMM. T.I TO OFFICE 800 SQ FT License Class Lic. # Contractor Date 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $20000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 32627036.00 Occupancy ,l ype: Section 3700 of the Labor Code, for the performance of the work for which this 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 WITfIIN 180 RAYS -9F 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 F OM 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 Issued b Y Date: 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. RE -ROOFS: Signature Date 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 co tract 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 1 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 Ara Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cu ino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Section 505, 25533 5534. Section 3700 of the Labor Code, for the performance of the work for which this �y Owner or authorized -----"" Date:' permit is issued. I certify that in the performance of the work for which this permit is issued, I shall employ any person in any manner so as to become subject to the Worker's -06 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. A tionally, the applicant understands and will comply with all non -point o, regulations ertmo Municipal Code, Section Licensed Professional 9.18. %/_mss ~Date Signat4� CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinp�cupertino.org r_1. _ V1 n ntvrcrnt I i n> FFIZRFTI nRIC:INAL PERMIT # II NEW CONSTRUCTION L_J ADDITION` I AL I r -NA I ikJIN / i I APN # `'I PROJECT ADDRESS 10100 M R \ - T Q` `/ IV u� PHONE E-MAIL OWNER NAME �p,�TrEE ZZ STREET ADDRESS 1 f j )� J f�, Q�'� ' £,��p, IT`-�-p,Pl ! \ / t i9I . ( 'C. 61404 1 FAX ` V/ \ 1"w V 1�/v�� CONTACT NAME 1 F r (� P�HnO`N'E("C,�) E-MAIIIL`t^V STREET ADDRESS �L1DO j�❑( DOWNER FAX 1:1 OWNER El OWNER-BUILDERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEERNANIE EGK Le LICENSE NUMBER Go g� l BUS. LIC # COMPANY NAMEn 4 Eig /_1. ` r, � � / i N C E-MAIL �, ` _ t-} -tI/n ' L WM STREET ADDRESS G� 1"YVvUSC,��VAi C'().A 2% ST �p 15 "1-W, �f, �O /SFS/A�,,X l` c .�,y��7'� 1,6V J✓ (� v"�i" DESCRIPTION OF WORK Ir1�Cl"'A(,}'1._A1n(M� D1�'_ dJ:7;:kGC EXISTING USE PROPOSED USE CONSTR. TYPE k STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG AREA NEW FLOOR AREA DEMO AREA TOTAL NET AREA BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH ❑ ATTACH #DWELLING UMTS: ISASECONDUNIT ❑YES BEING ADDED? []NO SECOND STORY ❑YES ADDITION? ❑NO T-1 PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING APPL 4 ❑ NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HONIE? ❑ NO RECEIVED BY:l TOTAL VALUATION: S ?� u. v v �i By my signature below, I certify to each of the g: I am the property owner or authorized agent to act on e property owner's behalf. I heave read this application and the information I have pr ed orrect. I h f Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relati t ildin on. I authorize representatives o u ertino to enter the abov identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TIDE ROUTING SLIP ❑ OVER THF -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. El EXPRESS El PLANNING PIANS REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARD El PUBLICWORKS _ 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 SEwFR DIsTRIc'r submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION PjADDRESS: 10100 maty ave TYPE OF CONSTR. I DATE: 06/17/2014 REVIEWED BY: Mendez PC FEE ID I APN: BP#: / `f lLo &0'/0 *VALUATION: 1$20,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: $0.00 $0.00 PENTAMATION 16 TI I PERMIT TYPE: WORK lenbrook apt- comm. t.i to office 800 sq ft SCOPE Permit Fee: Hourly Only? 0 Yes Q No OCCUPANCY TYPE: 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 0 $0.00 0.0 1 $0.00 $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. Fee:Q Reg. C) OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 0 $0.00 $0.00 MECH, HOURLY 0 Yes (F) No PLUMB, HOURLY Q Yes (D No ELEC, HOURLY Q Yes Q No MISC ITEMS I llifilb, hu)) r`. Other Liet, NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, fire, sanitarysewer uistrict, acnum n:_s_:... .. ,. TA....,. f ..o ....., An 1 ns• son ininrmatinn availahle and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 E . 7,/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 F 27 hours $278.00 Plan Check, Hourly 1STPLNCK Suppl. PC Fee: 0 Reg. Q OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. Fee:Q Reg. C) OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 F .'Onstruction TOA -TT ' '""HMr�t�lr11.1%> 1�'�;>�: O G) Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential 0 Building or Structure �11){>c°r�,rs�ratatirrrr't�>s_ Strong; Motion. Fee: IBSEISMICO $4.20 6.0 llrs $834.00 Inspections 1STINSP Inspection, Hourly Bldg Stds Commission Fee: IBCBSC $1.00 SU 13TOTALS: $5.201$1,112.001 TOTAL FEE: $1,117.20 Revised: 04/01/2014 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building6d)cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITEADDRESS O`l J � / APN BP#7 "Io OWNER E /V'I �1 � ` l�IC��Pvo� _(J) OWNER ADDRESS Cao tom," a5A—#, si- DESCRIPTION OF WORK:Qr-r- e� We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) L__KI understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 2 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. 6 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. --7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 `16 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. /,' 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: I - -- Before a building permit can be issued, this for must be completed and signed by the property owner and returned to the agency responsible for issuiWfhe permit. Note: A copy of the property owner's driver's license, form notarization, or other verificaticc Wble to the ci Xrpay-ba-rettCrir" be presented when the permit is issued to verify the property owner's signatur . Property Owner's Signatur _, Date: -------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderFornl 2010.doc revised 04/14/10 www.baaaengineers.com 7 info@baggengineers.com �� phone: 650.852.9133 fax: 650.852.9138 GG ENGINEERS 847 West Maude Avenue, Sunnyvale, California 94085-2911 SPECIAL INSPECTION REPORT Special Inspection Reports must be distributed to the parties listed below within 14 days of the inspection. Reports of non-compliant conditions must be distributed immediately. Separate reports shall be prepared for each type of special inspection, on a daily basis. Each report shall be completed and signed by the special inspector conducting the inspection. ------------- Project Name: Gle o Apt. Homes - Office enovation Date/Day: 10/27/2014 Mon. BAGG Project #: AVERY -14-01 Project Locatioi 10100 South Mary Ave. - Cupe Ino, CA. Contractor: A ry Construction Bldg Permit #: 14060107 Inspection Coverage: 0 Continuous ❑ Periodic ❑ Concrete ❑ Masonry ❑ Welding -Shop ❑ Prestressed Concrete ❑ High Strength Bolting ❑ Welding -Field ❑ Reinforcing Steel O Epoxy Bolts/Dowel ❑ other Approved Documents: Reviewed, Signed and Stamped Describe inspections made, including locations: Observed the epoxy (Simpson Set XP with expiration date 02/2016) and placement of four (4) WO all -thread (AT) rods (with min. 7" embed) per the Project's CONSTRUCTION DOCUMENTS: 5/S5.1 [Post Attachment into (E) Concrete], the Manufacturer's recommendations and ESR -2508. All drilled holes for the aforementioned installed WO AT rods were debris evacuated prior to epoxy/installation. NA Items requiring correction, corrections of previously listed items, and previously listed uncorrected items: None List changes to approved plans by architect or engineer: None Comments: None The Work O WAS ❑ WAS NOT Inspected in accordance with the requirements of the Building Department approved documents Material Sampling ❑ WAS ❑ WAS NOT O N/A Performed in accordance with the approved documents The Work Inspected 21 MET ❑ DID NOT MEET The requirements of the Building Official Approved Documents cc: Project Architect Structural Engineer Project Quality Engineer City Building Department Signature of Special Inspector Louis C. Smith / Field Technician Print Name / Title ACI# 00093077 Certification # SITE A DRESS V 5O� t`��A uS STATEMENT OF SPECIAL INSPECTIONS, 2013 CBC Bf� 0 Owner........ v�`R cp, �nd C .`............................................... ..r........................... � COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION t✓i0u 3 Address .13.0......E ,. .t�!........... ........................ . Address ............. ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL CUPERT"fmo 10300TORRE AVENUE • CUPERTINO, CA 95014-3255 Engineer/Architect.T� G... (408) 777-3228 • FAX (408) 777-3333 • building Cd)cuoertino. org SITE A DRESS V 5O� t`��A uS APN _ � o �j(� Bf� 0 Owner........ v�`R cp, �nd C .`............................................... ..r........................... � Contractor............................................................................................... t✓i0u 3 Address .13.0......E ,. .t�!........... ........................ . Address ............. City/St.. J.1/ . Zip. ................. Phone.Q1.' .dr%`.�.... City/St .... I ........................................ I ... ...............Pho�ne .......... Applicant ... v....LeA.(0.�......................................................... Engineer/Architect.T� G... ....��+.r,.. j►- Address.....V ..........e., ................................................. . �.....�....�..... ..... Adress..?vo.��/.0 -ci... C' /St......(! v �.' V ar-d.. Zip.... C,K..............fhone `�V; 0117 tY ................. .....t.Z-..i.pI.�....1... LVA.....i.../............,.Ci........... i pp ` t . c �� i (�S City/St.. .�. CPr .... Zip. C.7.4Phone ..............30. PROJECT DESCRIPTION: This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This form is structured after and used by permission from the Structural Engineer Association of Northern Califomia's (SEAONC) mode statement of Special Inspections. Also, included with this form is the following: ❑ "LIST OF SPECIAL INSPECTION AGENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the tests and inspections for this project ❑ 'SCHEDULE OF SPECIAL INSPECTION' (page 3 — 6). The Schedule of Special Inspections summarizes the Special Inspections and tests required. Special Inspectors will refer to the approved plans and specifications for detailed special inspection requirements. Any additional tests and inspections required by the approved plans and specifications shall also be performed. Special Inspections and Testing will be performed in accordance with the approve specifications, this statement and CBC Sections 1704, 1705, 1706, 1707, and 1708. Interim reports will be submitt Idi Official and the Registered Design Professional in Responsible Charge in accordance with CBC Sectio 2. A Final Report of Special Inspections document.Cfa a aaI ctions, testing and correction of any discrepancies noted in the inspections shall be submitted prior e of Use and Occupancy (Section 1704.1.2). The Final Report will document: • Required special in cti • Correction of discrep ci n ed in inspections. The Owner recognizes his or her obligation to ensure that the construction complies with the approved permit documents and to implement this program of special inspections. In partial fulfillment of these obligations, the Owner will retain and directly pay for the Special Inspections as required in CBC Section 1704.1. This plan has been developed with the understanding that the Building Official will: • Review and approve the qualifications of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their duties as called for in this Statement of Special Inspection. • Review submitted inspection reports. • Perform inspections as required by the local building code. 1 have read and agree to comply with the terms and conditions of this statement Prepared By: Project Engineer ❑ Architect Q Re is1teG r(ed Design Professional in Charge Signature.. ........................ ....................... #v......�......�..�.._.._....._._.. �...... at_e. Owner Name k6b 's Authorization -D_ Si natur � ................'...............................................;.................................................. Date:...../�.... ........ Inspection Agency / Inspector Name: r7C,7 Cos si nature ... ... .. .... ........ ................. ............. Lie.# ... (0 2S3 fv...... Date:.. �� .z . �..... Building Official or designee: Sinature ................ .............................................................................................. Date:/o...Z.l... ...... S SpecialnspectionForm_2012.doc revised 09106/12 LIST OF SPECIAL INSPECTION AGENCIES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre -approved and listed on Cupertino's approved Special Inspectors list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order" and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow two weeks to complete the application process. The following are the testing and s ecial inspection agencies that will be retained to conduct tests and ins ection on this roiect: EXPERTISE FIRM / INSPECTOR INFORMATION 1. Special Inspection (except for Firm..... Addr.... geotechnical City..... ............................................................. State ..... Zi 25"fC-76— F iielt0-t Telephone..rv�. ...:.��.:�i�3Fax..�j O'6.J.i'.9�38. a [n i/Itlrt .......................... 2. Material Testing Firm.. ................................................................... Addr ......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone.......................................Fax............................................ Email......................................................... 3. Geotechnicallnspections Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax ............................................ Email......................................................... 4. Other: Firm.....................................................................Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax............................................ Email......................................................... 'All agencies specified on this form must be pre -approved and listed on the City of Cupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismic -force -resisting system is defined in more detail in the construction documents. WIND REQUIREMENTS (Section 1705.4.1 Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialrupectionForm_2012. doc revised 09/06112 SCHEDULE OF SPECIAL INSPECTION SITEADDRESS 10 (00 MAt� # venue APN Q7/ �� BP# PROJECT DESCRIPTION: 7 �-�O Notation Used in Table: Column headers: C Indicates continuous inspection is required. P Indicates periodic inspections are required. The notes and/or contract documents should clarify. Box entries: X Is placed in the appropriate column to denote either "C" continuous or "P" periodic inspections. -- Denotes an activity that is either a one-time activity or one whose frequency is defined in some other manner. Additional detail regarding inspections and tests are provided in the project specifications or notes on the drawings. VERIFICATION AND INSPECTIONC P REFERENCED IBC REFERENCE STANDARD INSPECTION OF FABRICATORS 1. ❑ Inspect fabricator's fabrication and quality control 1704.3 procedures. INSPECTION OF STEEL 1. Material verification of high-strength bolts, nuts and washers. ❑ Identification marking to conform to ASTM stds AISC 360, specified in the approved construction documents. X Section A3.3 and applicable ASTM material standards ❑ Inspect fabricator's fabrication and quality control procedures. -- X '- '- 2. Inspection of high-strength bolting: ❑ Snug -tight joints. — X ❑ Pretensioned and slip -critical joints using turn -of -nut with matchmarking, twist -off bolt or direct tension -- X AISC 360, indicator methods of installation. Section M2.5 1704.3.3 ❑ Pretensioned and slip -critical joints using turn -of -nut without matchmarking or calibrated wrench methods X of installation. 3. Material verification of structural steel and cold -formed steel deck. ❑ For structural steel, identification markings to conform X AISC 360, to AISC 360. Section M2.5 ❑ For other steel, identification markings to conform to ASTM standards specified in the approved -- X Applicable ASTM construction documents, material standards ❑ Manufacturer's certified test reports. __ X Specialnspec(ionForm 2012. doc revised 09/06/12 VERIFICATION AND INSPECTIONC C P REFERENCED STANDARD IBC REFERENCE 4. Material verification of weld filler materials: ❑ Identification marking to conform to AWS specification in the approved construction documents. — X AISC 360, Section A3.5 and applicable AWS A5 documents — ❑ Manufacturer's certificate of compliance required. --- X --- -- 5. Inspection of welding: a. Structural steel and cold -formed steel deck: ❑ Complete and partial joint penetration groove welds. X --- AWS D1.1 1704.3.1 ❑ Multipass fillet welds. X -- ❑ Single -pass fillet welds > 5/16" X -- ❑ Plug and slot welds. X ___ ❑ Single -pass fillet welds <= 5/16" -- X ❑ Floor and roof deck welds. — X AWS DU b. Reinforcing steel: ❑ Verification of weldability of reinforcing steel other than ASTM A 706. — X AWS D1.4 ACI 318: Section 3.5.2 _ ❑ Reinforcing steel resisting flexural and axial forces in intermediate and special moment frames, and boundary elements of special structural walls of concrete and shear reinforcement. X — ❑ Shear reinforcement. X --- ❑ Other reinforcing steel. --- X 6. Inspection of steel frame joints details for compliance: ❑ Details such as bracing and stiffening. -- X --- 1704.3.2 ❑ Member locations. -- X ❑ Application of joint details at each connection. -- X VERIFICATION AND INSPECTION C P REFERENCED STANDARD IBC REFERENCE INSPECTION OF WELDING 1. ❑ Welded studs when used for structural diaphragms. — X -- 1704.3 2. ❑ Welding of cold -formed steel framing members. -- X 3. ❑ Welding of stairs and railing systems. -- X SpecialnspechonForm 2012. doc revised 09/06/12 VERIFICATION AND INSPECTION CP REFERENCED IBC STANDARD REFERENCE INSPECTION OF CONCRETE 1. ❑ Inspection of reinforcing steel, including prestressing _ X ACI 318: 3.5, 7.1-7.7 1913.4 tendons and placement. 2. ❑ Inspection of reinforcing steel welding in accordance AWS D1.4 ACI 318: with Table 1704.3 Item 5b. _ 3.5.2 _ 3. ❑ Inspection of bolts to be installed in concrete prior to and during placement of concrete where allowable X - ACI 318: 8.1.31 1911.5, 1912.1 loads have been increased or where strength design 21.2.8 is used. 4. ❑ Inspection of anchors installed in hardened concrete. -- X ACI 318: 1912.1 5. ❑ Verifying use of required design mix. 1904.2.2,1913.2, X ACI 318: 1913.3 6. ❑ At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength tests, perform slump and air X - ASTM C 31 1913.10 content tests and determine the temperature of the concrete. AC 1318: 5.6, 5.8 7. ❑ Inspection of concrete and shotcrete placement for X - ACI 318: 5.9, 5.10 1913.6, 1913.7, proper application techniques. 1913.8 8. ❑ Inspection for maintenance of specified curing X ACI 318: 5.11-5.13 1913.9 temperature and techniques. 9. Inspection of prestressed concrete: ❑ Application of prestressing forces. X - ACI 318: 18.20 ❑ Grouting of bonded prestressing tendons in the X -- ACI 318: 18.18.4 -- seismic force-resisting system. 10. ❑ Erection of precast concrete members. - X ACI 318: Ch. 16 - 11. ❑ Verification of in-situ concrete strength, prior to stressing of tendons in posttensioned concrete and - X ACI 318: 6.2 --- prior to removal of shores and forms from beams and structural slabs. 12. ❑ Inspect formwork for shape, location, and dimensions - X ACI 318: 6.6.1 - f the concrete member being formed. 13. fif Bolts Installed in Existing 44asecAs}.Q;�-Concrete ❑ Direct tension testing of existing anchors. --- X See ICC ES Reports form special inspection requirements for proprietary ❑ Direct tension testing of new bolts. X ❑ Torque testing of new bolts. __ X products ❑ Prequalification test for bolts and other types of X anchors. 14. ❑ Other SpecialnspectionForm_2012.doe revised 09106112 Specia1nspec1ionForm_2012.doc revised 09/06/12 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 INSPECTION OF LEVEL 1 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved -- X --- -- Art. 1.5 submittals shall be verified. 2. ❑ Verification of f. and f AAG prior to construction — X — — Art. 1.413 except where specifically exempted by this code. 3. ❑ Verification of slump flow and VSI as delivered to X — — --- Art. 1.5B.1.b.3 the site for self consolidating grout. 4. As masonry construction begins, the following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar. — X -- — Art. 2.6A ❑ Construction of mortar joints. — X — — Art. 3.38 ❑ Location of reinforcement, connectors, X -- -- Art. 3.4, 3.6A prestressing tendons, and anchorages. ❑ Prestressing technique. -- X — -- Art. 3.613 ❑ Grade and size of prestressing tendons and _ X — -- Art. 2.48, 2.4H anchorages. 5. During construction the inspection program shall verify: ❑ Size and location of structural elements. — X -- --- Art. 3.3F ❑ Type, size, and location of anchors, including Sec. 1.2.2(e), other details of anchorage of masonry to — X — 1 16 1 -- structural members, frames or other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and — X — Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X — — — ❑ Preparation, construction and protection of masonry during cold weather (temperature below _ _ X Sec. 2104.3, — Art. 1.8C, 1.81) 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing X — — -- Art. 3.613 force. 6. Prior to grouting the following shall be verified to ensure compliance: ❑ Grout space is clean. -- X — -- Art. 3.2D ❑ Placement of reinforcement and connectors and — X --- Sec. 1.3 Art. 3.4 prestressing tendons and anchorages. ❑ Proportions of site -prepared grout and — X — — Art. 2.68 prestressing grout for bonded tendons. ❑ Construction of mortar joints. -- X — --- Art. 3.38 7. Grout placement: ❑ Grout placement shall be verified ensure X — — -- Art. 3.5 compliance. ❑ Observe grouting of prestressing bonded X --- --- -- Art 3.6C tendons. Specia1nspec1ionForm_2012.doc revised 09/06/12 SpecialnspectionForm_2012.doc revised 09/06/12 REFERENCE FOR CRITERIA VERIFICATION AND INSPECTION C P IBC TMS 402/ACI TMS 402/ACI SECTION 530/ASCE 5 530/ASCE 6 8. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be --- X 2105.2.2, — Art. 1.4 observed. 1 12105.3 INSPECTION OF LEVEL 2 MASONRY 1. ❑ Compliance with required inspection provisions of the construction documents and the approved --- X --- — Art. 1.5 submittals. 2. ❑ Verification of f m and f AAC prior to construction and for every 5,000 square feet during -- X -- — Art. 1.46 construction. 3. ❑ Verification of proportions of materials in premixed or preblended mortar and grout as -- X — — Art. 1.513 delivered to the site. 4. ❑ Verification of slump flow and VSI as delivered to X --- — — Art. 1.513.1.b.3 the site for self consolidating rout. 5. The following shall be verified to ensure compliance: ❑ Proportions of site -prepared mortar, grout, and _ X --- __ Art. 2.6A prestressing grout for bonded tendons. ❑ Placement of masonry units and construction of mortar joints. -- X — -- Art. 3.36 ❑ Placement of reinforcement, connectors and — X — Sec. 1.15 Art. 3.4, 3.6A prestressing tendons and anchorages. ❑ Grout space prior to grouting. X -- — — Art. 3.2D ❑ Placement of grout. X — – — Art. 3.5 ❑ Placement of prestressing grout. X --- -- — Art. 3.6C ❑ Size and location of structural elements. -- X — -- Art. 3.3F ❑ Type, size, and location of anchors, including other details of anchorage of masonry to X --- -- Sec. 1.2.2(e) — structural members, frames and other construction. ❑ Specified size, grade, and type of reinforcement, anchor bolts, prestressing tendons and -- X -- Sec. 1.15 Art. 2.4, 3.4 anchorages. ❑ Welding of reinforcing bars. X – Sec. 2.1.9.7.2, — 3.3.3.4 (b) ❑ Preparation, construction, and protection of masonry during cold weather (temperature below – X Sec. 2104.3, — Art. 1.8C, 1.8D 40 degrees F) or hot weather (temperature above 2104.4 90 degrees F). ❑ Application and measurement of prestressing force. X _ — — Art. 3.66 6. ❑ Preparation of any required grout specimens, Sec. mortar specimens, and/or prisms shall be X -- 2105.2.2, — Art. 1.4 observed. 2105.3 SpecialnspectionForm_2012.doc revised 09/06/12 VERIFICATION AND INSPECTIONC p REFERENCED IBC STANDARD REFERENCE INSPECTION OF WOOD 1. ❑ Inspect prefabricated wood structural elements and assemblies in accordance with Section 1704.2. — 1704.6 2. ❑ Inspect site built assemblies. --- — 3. Inspect high -load diaphragms: ❑ Verify grade and thickness of sheathing. -- --- ❑ Verify nominal size of framing members at adjoining paneledges. -- -- — 1704.6.1 ❑ Verify nail or staple diameter and length, — — ❑ Verify number of fastener lines, -- — ❑ Verify spacing between fasteners in each line and at edge margins. — -- 4_ ❑ Metal -plate -connected wood trusses spanning 60 feet or greater: Verify temporary installation restraint/bracing and the permanent individual truss -- X -- 1704.6.2 member bracing are installed in accordance with the approved truss submittal package. REQUIRED VERIFICATION AND INSPECTION OF SOIL 1. ❑ Verify materials below footings are adequate to — X achieve the desired bearing capacity. 2. ❑ Verify excavations are extended to proper depth and _ X have reached proper material. 3. ❑ Perform classification and testing of compacted fill X materials. — Table 1704.7 4. ❑ Verify use of proper materials, densities and lift thicknesses during placement and compaction of X — compacted fill. 5. ❑ Prior to placement of compacted fill, observe subgrade — X and verify that site has been prepared properly. REQUIRED VERIFICATION AND INSPECTION OF DEEP DRIVEN FOUNDATION ELEMENTS 1. ❑ Verify element materials, sizes and lengths comply X with the requirements. 2. ❑ Determine capacities of test elements and conduct X -- additional load tests, as required. 3. ❑ Observe driving operations and maintain complete X — and accurate records for each element. 4. ❑ Verify locations of piles and their plumbness, confirm type and size of hammer, record number of blows per — Table 1704.8 foot of penetration, determine required penetrations to X -- achieve design capacity, record tip and butt elevations and document any damage to foundation element. 5. ❑ For steel elements, perform additional inspections in accordance with Section 1704.3. 6. ❑ For concrete elements and concrete filled elements, perform additional inspections in accordance with --- --- Section 1704.4. SpecialnspectionForm_2012.doc revised 09/06/12 VERIFICATION AND INSPECTION C P REFERENCED IBC STANDARD REFERENCE 7. ❑ For specialty piles, perform additional inspections as determined by the registered design professional in responsible charge. --- -- — Table 1704.8 REQUIRED VERIFICATION AND INSPECTION OF CAST -IN-PLACE DEEP FOUNDATION ELEMENTS 1 ❑ Observe drilling operations and maintain complete and X accurate records for each element. 2. ❑ Verify placement locations and plumbness, confirm element diameters, bell diameters (if applicable), lengths, embedment into bedrock (if applicable), and X — Table 1704.9 adequate end -bearing strata capacity. Record concrete or grout volumes. 3. ❑ For concrete elements, perform additional inspections in accordance with Section 1704.4. _ HELICAL PILE FOUNDATIONS 1. ❑ Record installation equipment used, pile dimensions, X — -- 1704.10 tip elevations, final depth, final installation torque. SPRAYED FIRE-RESISTANT MATERIALS Physical and visual tests 1. Condition of substrates. ❑ Inspect surface for accordance with the approved fire - resistance design and the approved manufacturer's — -- written instructions. ❑ Verify minimum ambient temperature before and after — X application. ❑ Verify ventilation of area during and after application. -- X 2. ❑ Measure average thickness per ASTM E605 and Section 1704.12.4. — -- -- 1704.12.1 3. ❑ Verify density of material for conformance with the approved fire-resistant design and ASTM E605. (Ref. — -- Section 1704.12.5) 4. ❑ Test cohesive/adhesive bond strength per Section 1704.12.6. _ -- 5. ❑ Condition of finished application. MISCELLANEOUS 1. Mastic and Intumescent Fire -Resistant Coating. --- — --- 1704.13 2. Exterior Insulation and Finish Systems (EIFS). Water - resistive barrier coating when installed over a sheathing --- -- --- 1704.14 substrate. 3. Special Cases --- --- -- 1704.15 4. Smoke Control System — — __ 1704.16 5. Seismic Resistance ❑ Suspended ceiling systems and their anchorage. -- --- -- 1705.3 [4.3] SpecialrupechonForm 2012. doe revised 09/06112 VERIFICATION AND INSPECTION C p REFERENCED IBC STANDARD REFERENCE 6. Wind Resistance ❑ Roof cladding and roof framing connections. — — -- ❑ Wall connections to roof and floor diaphragms and framing. ❑ Roof and floor diaphragm systems, including collectors, drag struts and boundary elements. — ❑ Vertical wind -force -resisting systems, including braced frames, moment frames, and shear walls. — ❑ Wind -force -resisting system connections to the foundation. — _ ❑ Fabrication and installation of systems or components required to meet the impact resistance requirements --- -- of Section 1609.1.2. SPECIAL INSPECTION FOR WIND REQUIREMENTS 1. Structural Wood ❑ Inspect field gluing operations of elements of the main X — wind -force -resisting system. — 1706.2 ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the main windforce-resisting _ X system, including wood shear walls, wood diaphragms, drag struts, braces and hold-downs. 2. Cold -Formed Steel Framing ❑ Welding of elements of the main wind -force -resisting — X system. ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the main — 1706.3 wind -force -resisting system including shear walls, — X braces, diaphragms, collectors (drag struts) and hold- downs. 3. Wind -resisting components ❑ Roof cladding. — X -- 1706.4 ❑ Wall cladding. — X SPECIAL INSPECTIONS FOR SEISMIC RESISTANCE 1. ❑ Special inspection for welding in accordance with theX _ 1707.2 quality assurance plan requirements of AISC 341. 2. Structural Wood ❑ Inspect field gluing operations of elements of the X --- seismic-force-resisting system. ❑ Inspect nailing, bolting, anchoring, and other fastening of components within the seismic -force -resisting 1707.3 system, including wood shear walls, wood — X diaphragms, drag struts, braces, shear panels and hold-downs. 3. Cold -Formed steel light -frame construction ❑ Welding of elements of the seismic -force -resisting system. _ X 1707.4 SpecialnspectionForm_2012.doc revised 09/06/12 ❑ Inspection of screw attachments, bolting, anchoring, and other fastening of components within the seismic- — X force -resisting system including shear walls, braces, diaphragms, collectors (drag struts) and hold-downs. 4. Storage racks and access floors ❑ Anchorage of storage racks 8 feet or greater in height and access floors. _ X 1707.5 5. Architectural components ❑ Inspect erection and fastening of exterior cladding weighing more than 5 psf and higher than 30 feet above grade or walking surface. — X ❑ Inspect erection and fastening of veneer weighing more than 5 psf.and higher than 30 feet above grade — X or walking surface. — 1707.6 ❑ Inspect erection and fastening of all exterior non- bearing walls higher than 30 feet above grade or walking surface. — X ❑ Inspect erection and fastening of all interior non- bearing walls weighing more than 15 psf and higher — X than 30 feet above grade or walking surface. 6. Mechanical and Electrical Components ❑ Inspect anchorage of electrical equipment for — X emergency or stand-by power systems. ❑ Inspect anchorage of non -emergency electrical — X equipment. ❑ Inspect installation of piping systems and associated mechanical units carrying flammable, combustible, or — X -- 1707.7 highly toxic contents. ❑ Inspect installation of HVAC ductwork that contains — X hazardous materials. ❑ Inspect installation of vibration isolation systems — X where required by Section 1707.7. 7. ❑ Verify that the equipment label and anchorage or mounting conforms to the certificate of compliance — 1707.8 when mechanical and electrical equipment must be seismically qualified. 8. ❑ Seismic isolation system: Inspection of isolation — X — 1707.9 system per ASCE 7 – Section 17.2.4.8 9. ❑ Obtain mill certificates for reinforcing steel, verify compliance with approved construction documents, — -- -- 1708.2 and verify steel supplied corresponds to certificate. 10. ❑ Structural Steel: Invoke the QAP Quality Assurance 1708.3 requirements in AISC 341. 11. ❑ Obtain certificate that equipment has been seismically — — 1708.4 qualified. 12. ❑ Obtain system tests as required by ASCE 7 Section -- --- — 1708.5 17.8. SpeciaimpectionForm_2012.doc revised 09/06112