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B-2016-3236 it Yo CITY OF CUPERTINO BUILDING P RMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3236 19000 HOMESTEAD RD UNIT 1 CUPERTINO,CA 95014-0716(316 09 036) KAISER FOUNDATIpN HEALTH PLAN INC I ANAHEIM,CA 92807 OWNER'S NAME: ARC KFCPTCA001 LLC DATE ISSUED:12/20/2016 OWNER'S PHONE:408-590-4756 PHONE NO:(714)572-7401 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class I3 Lic.#370871 Contractor MISER FOUNDATION HEALTH PLAN INC Date 03/31/2017 X BLDG X VI,ECT _PLUMB MECHRESIDENTIAL X COMMERCIAL I hereby affirm that I am licensed under the provisions of Chapter 9(commencing — — with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: UNIT 1-T.I.-REPLACE(94)LIGHT FIXTURES AND(19)WALL I hereby affirm under penalty of perjury one of the following two declarations: SWITCHES WITH DIMMERS;NON OSHPD FACILITY-KAISER 1. I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the -performance of the work for which this permit is issued. 2; I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$106542.00 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 APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 316 09 036 A(Tenant Improvements) representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT E IRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 1 SO DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cu.:i',. u I.rpal Code,Section 9.18. 180 DAYS F OM LAST CALLED INSPECTION. Signature Date 12/20/2016 Issued by:AbbyAyende Date: 12/20/2016 OWNER-BUILDER DECLARATION • I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS; following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. sale(Sec.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:12/20/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF OVERINGS TO BE CLASS"A"OR BETTER 1. I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. NATJRDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health bazar Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance th the Cupertino Municipal Code,Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally,(should I use equipment or devices which emit hazardous air contaminants as delned by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliana with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health& afety Code,Sections 2 I_ 25533 j d 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. 4G` Owner or authorized ge.t: APPLICANT CERTIFICATION (•,Date:12/20/2016 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that they is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this ermit is issued(Sec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. I understand my plans hall be used as public records. Licensed Signature Date 12/20/2016 Professional I • �/ CONSTRUCTION PERMIT APPLIC TION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDIN DIVISION tos-i%,,Js 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•buildingt cupertin .orq 0 NEW CONSTRUCTION 0 ADDITION N ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# 3 PROTECT ADDRESS 19000 Homestead Rd. Cupertino, CA 95014 \) pPN# ,-hus, l.J-l'V2 OWNER NAME Kaiser Foundation Health Plan Inc. PHONE 408-590-47561 - E-MAIL STREET ADDRESS 700 Lawrence Expressway CITY,STATE,ZIP Santa Clara, CA 95051 FAX CONTACT NAME t ('') 1I� PHONE E-MAIL (( C{ NI1GII'16F.1 Q Zelle. Live•55Q© -'i-c IhiG 1.ekLT.e la wit, .Gr.5 STREET ADDRESS CITY,STATE,ZIP FAX J 760 ]..awl^ance- exrrasfwe.1 Sc.n4-a- G(a_ra GA. IgS0S( 4091 -SS( - OreSg ❑OWNER 0 OWNER-BUILDER 0 OWNER AGENT gi CONTRACTOR 0 CONTRACTOR AGENT q ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT CONTRACTOR NAMEI- LICENSE NUMBER :.ICENSE TYPE BUS.LIC# • IA;41,,..e.1 R:Gin C, 37097k COMPANY NAME f I ,eI FAX Kalse.r rf eu�r► ion I-4e.d`�, Plo.v. *anc rn,Ghae.i•t^iahiat?„ Kr•0rq `1159-SSl- 069$ STREET ADDRESS CITY,STATE ZIP I �J PHONE 766 Lawrence_ E.xpre5scoo, S..r,--ct G(o.ect.i 6A 9S6Sl Lto8- 540 -4750 ARCI-IITECT/ENGINEERNAME Joe Bazzell LICENSE NUMBER E014396 BUS.LIC# COMPANY NAME Silverman&Light E-MAIL info@Silver anlight.com FAX STREET ADDRESS 120 Park Ave., Suite 100 CITY,STATE,ZIP Emeryville, A 94608 PHONE 510-655-1200 DESCRIPTION OF WORK Update of existing luminaires to LED luminaires. - 0� - `�iD (- \‘; 7 os--rim 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 AREA TOTAL DECK/PORCH AREA GARAGE AREA: 0 DETACH 0 ATTACH P DWELLLNG UNITS: ISA SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ONO ADDITION? ONO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN 0 YES RECEIVED BY: TOTAL VALUATION: PLANNING APPL# 0 NO PLANNING APPROVAL LEDER EICHLER HOME? 0 NO 4'gam, ,q 45S- By S- By my signature below,I certify to each of the following: I am the property owner or authorized agent to act 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 ccurate. I agree to comply withcn all applicable local ordinances and state laws relating to buildi •c.. s. . -. .,. : thorize representatives of Cupertino to enter th above-identified property for inspection purposes. Signature of Applicant/Agent: r� / ��- Date: 12. - 7 - I w SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OYE ❑ BUILDING PLAN existing building(s). Demolition permit is required prior to issuance of building OYER-THE-C: REVIEW„ - lI UNTER permit for new building. ❑ EXPRESS 0 PLANNING PLAN REVIEW I Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 0 STANDARD 0 'UBLIC woiucs I form if any Hazardous Materials are being used as part of this project. 0 LARGE 0 FIRE DSL . I Copy of Planning Approval Letter or Meeting with Planning prior to MAJOR 0 SANITARY SEWER DISTRICTsubmittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp 2011.doc revised 06/21/11