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141200451AAi CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10100 N TANTAU AVE I CONTRACTOR: NOVO CONSTRUCTION I PERMIT NO: 14120045 1 OWNER'S NAME: CUPERTINO GATEWAY PARTNERS LLC 11460 O'BRIEN DR I DATE ISSUED: 12/08/2014 1 OWNER'S PHONE: 4087834731 1 MENLO PARK, CA 94025 1 PHONE NO: (650)701 -1500 ,A- LICENSED CONTRACTOR'S DECLARATION License Class Lic.# 19 A Contractor 4i0sa e6mu'LurI , Date g ? &�_ 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 l i ereby affirm under penalty of perjury one of the following two declarations: 1 have and will maintain a certificate of consent to self- insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the 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 permit is issued. APPLICANT CERTIFICATION 1 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, costs, and expenses which may accrue against said City in consequence of the 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. e Signature //L nlL/ ❑ OWNER - BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the 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 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 1 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 indemnity 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL APPLE T.I. - 1ST FLR FOR AN INTERIOR REMODEL & RECONFIGURATION (900 S.F.) Sq. Ft Floor Area: Valuation: $350000 APN Number: 31619061.10100 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 18 PERMIT ISSUANCE OR 180, F T CALLED INSPECTION. Issue V: te: Z g RE- ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &Safety Code, Sections 25505, 25533, an 25534. �y Owner or authorized agent: Date: D CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Add ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Licensed Professional 4 CITY OF CUPERTINO BUILDING PERMIT BUILDIING ADDRESS: 10100 N TANTAU AVE CONTRACTOR: NOVO CONSTRUCTION PERMIT NO: 14120045 OWNER'S NAME: CUPERTINO GATEWAY PARTNERS LLC 1460 O'BRIEN DR DATE ISSUED: 12/08/2014 OWNER'S PHONE: 4087834731 MENLO PARK, CA 94025 PHONE NO: (650)701 -1500 4/kA. LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑ APPLE T.I. - 1ST FLR FOR AN INTERIOR REMODEL & License Class Lic. # 1 % � a ea' RECONFIGURATION (900 S.F.) 117�} Contractor JV0 ✓a � glp�,t,'('j -, Date `� /5 I hereby affirm that 1 am licensed under the provisions of Chapter 9 REVISION #I- ADDITION OF PLUMBING N2 LINE TO LAB (commencing with Section 7000) of Division 3 of the Business & Professions EQUIPMENT,(N2 IS EXISTING IN BLDG)- ISSD 4/13/2015 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: $350000 performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 31619061.10100 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STAR'T'ED 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 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: 1 with all non -point source regulat' ns per the Cupertino Municipal Code, Section RE- ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is 9.18. �-�' Signatures z o— Date rr installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER- BUILDER DECLARATION Signature of Applicant: Date: 1 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 [, 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). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 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 unici ode, Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 33 5534. Section 3700 of the Labor Code, for the performance of the work for which this [f 3 permit is issued. Owner or authorized agent: Date: 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, 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 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 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION x,30 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 \ (408) 777 -3228 ^ FAX (408) 777 -3333 • buildingPcupertino.org ❑ NEW CONSTRUCTION rr�—I I—J ADDITION ® ALTERATION /T] ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 10100 N. Tantau —7AINI- / /1 r / O O l OWNER NAME Apple, Inc. �. PHONE 408 - 783 -4731 E-MAIL gallen @alppplle.com STREET ADDRESS 1 Infinite Loop CITY, STATE, ZIP Cupertino, CA 95014 FAX CONTACT NAME Mike DiMonaco PHONE 650.399 -5449 E- MAILmdimonaco @novoconstruction.com STREET ADDRESS 1460 O'Brien Dr. CITY, STATE, "LIP Menlo Park, CA 94025 FAX ❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT L'] CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME Mike DlMonaco LIC ENSF. NUMBER 791022 LICENSE TYPE B BUS. LIC # COMPANY NAME Novo Construction E -MAII• mdimonaco @novoconstruction.com FAX STREET ADDRESS 1460 O'Brien Dr. CITY, STATE, ZIP Menlo Park, CA 94025 PHONE 650- 399 -5449 ARCHITECT /ENGINEER NAME David Whitney LICENSE NUMBER BUS. LIC # COMPANY NAME Whitney Polcyn Architects E-MAIL david@whitneypolcyn.com FAX STREET ADDRESS 2185 The Alameda, Suite 100 CITY, STATE, 'LIP San Jose, CA 95126 PHONE 408 - 627 -9123 DESCRIPTION OF WORK Demolition of existing ceiling and existing non load bearing partition, Installing new T -bar ceiling and ceiling channel. Replacing single swing door with uneven pair of doors and relocating card reader for access. Installing electrical and data wiremold runs on partitions and on ceiling plane. Installing VAC and CDA drops. Relocating mechanical air returns and diffusers and framing and cooling a new air tight closet for equipmen EXISTING USE PROPOSED USE CONSTR. TYPE H STORIES Office /Lab I OfficefLab VB 1 USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL 0 AREA 950 AREA 950 AREA NET AREA Lab B V 990 $350,000 BATHROOM KITCHEN O'MER REMODELAREA REMODELAREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: HDETACH ATTACH # DWELLING UNITS: IS A SECOND UNIT YES SECONDS "1'OR \' CITES BEING ADDED? []NO ADDITION? []NO PRF- APPLICATION DYES IF YES. PROVIDE COPY OF IS THE BLDG AN ❑ YES RECF TOTAL VALUATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO 000 By my signature below, l certify to each of the following: I am the operty owner orauthorize agent to ac on t y owner's behalf I have read this application and the information I have provided is correct I hav ad the Description of Work and verify i curate. f agree to comply with all applicable local ordinances and state laws relating to buildin struction. orize representatives of Cupertino to enter the above- identifi d property for inspection purposes. Signature of Applicant /Agent Date: a6 SUPPLEMENTAL INFORMATION REQUIRED PLAN CIIECKTYVE ROUTING SLIP ❑ OVER THE COUNTER ❑ BUILDING New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building - - PLAN REVIEW permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ 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 ❑ NI AJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgt4pp_2011.doc revised 06121111 CUPERTINO n rrrw rnr,Ic7-PT trTtnu CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 FAX (408) 777 -3333 ^ buildiing(c- bcuDertino.ora. n &T)T1iTTrw I ATTPRA7014/7 U RFVTCTON /DEFERRED �T ORTCTMALPERMTT» 1 q, 7Ile,L � PRO]ECrADDRESS - APN9 l -/ Q((• r r- OWN'ER NAME PHONE E -MAIL STREET ADDRESS CITY, STATE, ZIP. FAX r ��� �� �err,�o e CONTACT NAME "" / PHONE. E -MAIL `V zr_x (050-Colo- %(Ow Albu E Y e- (4tl�Co STREET ADDRESS"-" CITY, STATE, ZIP 9`125 FAX Sri L' oAgzK " '❑ owNER -B.mi) R.`` • ` ❑ ORyNERAGENT CONTRACTOR ,- ❑ CONi- ACTORAGEN7 -" ❑ ,ARCHITECT ❑ ENGINEER:.,",: q DEVELOPER- "0" TENANT CON7MACTORNAME LICENSE NUMBER LICENSE TYPE BUS.I.IC� COMPANY NAME EMAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHTECT/ENGIN'EER NAM LICENSE NUMBER Qra,roJa BUS. LIC 9 , v 1� _' COMPANY NAAG: E -MAIL FAX W -r F« ,a ARC-4 0 11J. Cl�'M STREET ADDRESS CrIY STATE Z PHONE4r�.�2 L 41��A /v I�Z3 DESCRIPTION OF WORK Ay>,c�wrte4 pir g&m2&d4 AJz 1we -- 1 3 cQePm4gkj r s EXISTING U E PROPOS D USE CONSTR TYPE # STORIES �a� T. V3 1 USE TYPE OCC. SQ.FT. VALUATION (S) EXISTO AREA NEW FLOOR AREA DEMO AREA TOTAL N'ET AREA q /' t} ++ ., BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCB AREA DECK AREA TOTAL DECY PORCH AREA GARAGE ARZ—ATD DETACH ❑ ATTACH T__ R DWELLING UNTrs: IS A SECOND UNIT ❑YES SECOND STORY [DYES BEING ADDED? EINO ADDITION? ❑NO A` PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF I NO PLANT'APPROVALLET= PLANMNG APPL ° ❑ n�G IS THE BLDG AN ❑ YES £1CHLER HOAIE? ❑ NO }TECEIVED 8 } 5 � � .. TO TION: _.�.� y z t- _ i�i�.=� By my signature below, I certify to each of the following: I am the property owner or authorized agent to ac he property ommer'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 la%vs relating to building const tio. I authorize representatives of Cupertino to enter the above- identified for inspection purposes. /property Signature of ApplicanUAgent: ` Dare: 1 SUPPLE -MENTAL INFORMATION REQUIRED,,ztr ,;� � ELAlt CHECKTYPE � 5� ,� ��_ �ROUT:IItGSLIP y� � � New SFD or Multifamily dwellings: Apply for demolition permit for Zw� F0A7ERTHEC:6UNTER"� `BIIII.,D]?�GPL4NRE�:LE}q�' existing building(s). Demolition permit is required prior to issuance of building y' permit for new building. ff --� EXPRESS�� is PST ANn;inG nittE zEt} Commercial Bldgs: Provide a completed Hazardous Materials Disclosure C7 sTaxnaD r '� �1] PiBLTewn�iics a _ form if any Hazardous Materials are being used as part of this project. z 4 t h x I�`igREDEPT _ Copy of Planning Approval Letter Or Meeting with Planning. prior to 2rz © T4AJ6R -�... - £ submittal of Building Permit application. ,flSANTTARYSE\i'ERDISTRIC: BldgApp_2011.doc revised 06121111 ww'o' CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION 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 nreliminarv, information available and are only an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11 -053 Eff 711113) ADDRESS: 10100 n tantau ave DATE: 03/26/2015 REVIEWED BY: Mendez f"T Perfuit Fee: APN: BP #: *VALUATION: 1$4,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: Plunih. Iusp. Fee: PENTAMATION 1GENCOM PERMIT TYPE: � WORK addition of plumbing N2 line to lab a ui ment N2 is existing in bid SCOPE 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 nreliminarv, information available and are only an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11 -053 Eff 711113) Alecil. Ptah Check Pltunh. Plan Check Elec. Ilan Check f"T Perfuit Fee: Plumb, Permit Fee: 17ec. Permit Fee: ocher 'I'lech. Irup Other Plumb Ins. U7her Eke. Insp. Li Mech. Imp. /-I e: Plunih. Iusp. Fee: Glec. Irisp. Fee: 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 nreliminarv, information available and are only an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11 -053 Eff 711113) FEE QTY /FEE MISC ITEMS Plan Check Fee: Hourly Only? () Yes Q No $0.00 = hours $286.00 Plan Check, Hourly ISTPLNCK Suppl. PC Fee: Q Reg. Q OT 1 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? C) Yes Q No $0.00 Suppl. Insp. Fee.0 Reg. Q OT :0:0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Admin strotive Fee: Q Work Without Permit? ® Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Building or Structure (� Travel Documentation Fees: Strong Motion Fee: IBSEISMICO $1.12 2.0 hrs $286.00 Inspections ISTINSP Inspection, Hourly Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $2.12 $572.00 TOTAL FEE: 1 $574.12 Revised: 02/14/2015 FF CI TY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION OCCUPANCY TYPE: ADDRESS: 10100 N TANTAU AVE DATE: 1210812014 REVIEWED BY: MELISSA PC FEES APN: 4087834731 BP #: l7<c�?oo *VALUATION: 1$350,000 `°PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY USE: Commercial Building PENTAMATION 1 B TI PERMIT TYPE: WORK APPLE T.I. - 1ST FLR FOR AN INTERIOR REMODEL & RECONFIGURATION 950 S.F. SCOPE 1 -.7ec. Insp. 1 ^ec: 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 900 $2,128.56 IBTIPLNCK $998.16 IBTIINSP 1 -.7ec. Insp. 1 ^ec: $0.00 Pen-nit Fee: $998.16 Suppl. Insp. Fee:Q Reg. COT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 900 $2,128.56 $998.16 MECH, HOURLY Q Yes Q No PLUMB, HOURLY C) Yes Q No ELEC, HOURLY Q Yes Q No ;.. ,I. P ?c;? f' /•rre•'. t'lronh. Plon t hct.-h %'lea'. flan Check t;, ./I l'ernril Fee: Pl:,onh. Permit Fear: l lec. Pernnit Fee: to i h. 'r. 0;hel. Pllmh Imp Ofhei, L lee. Insp. Li 4 crt ker ' Plwld'. hiss. I've: 1 -.7ec. Insp. 1 ^ec: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, eta). These fees are based on the Dreliminary information available and are onlv an estimate. Contact the Dent for addn'l info. ]FEE ITEMS (Fee Resolution 11 -053 E(: 7/1/13) FEE QTY /FEE MISC ITEMS Plan Check Fee: $2,128.56 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 Pen-nit Fee: $998.16 Suppl. Insp. Fee:Q Reg. COT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? ® Yes 0 No $0.00 Advanced Planning Fee. $0.00 Select a Non - Residential Building or Structure Q 8 Strong Motion Fee: IBSEISMICO $98.00 Select an Administrative Item Blde Stds Commission Fee: 1BCBSC $14.00 SUBTOTALS: $3,238.72 $0.00 TOTAL FEE: 1 $3,238.72 Revised: 10101/2014 CUi'0f11.iM PURPOSE HAZARDOUS � a EF; aLS C ECKLIST COMMUNITY DEVELOPMENT DEPARTMENT ^ BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE ^ CUPERTINO, CA 95014 -3255 (408) 777 -3228 - FAX (408) 777 -3333 ^ building(a)cupertino.org To minimize possible delays that would result for the Fire Department plan review, please complete the following checklist to determine if an additional level of Hazardous Materials plan review will be required. ilAARK `YES' IF THE PROPOSED SCOPE OF WORK INCLUDE ANY OF THE FOLLOWING? PLEASE MARK YOUR ANSWER WITH AN 'X' IN THE YES OR NO BOX ON THE SIDE BELOW. YES NO 1. Use, dispensing, mixing or storage of flammable or combustible liquids or gases, hazardous materials, etc. 2. Battery back -up rooms or racks. \/ 3. Propane tanks. `h 4. Gasoline stations with underground tanks. ) �Jk 5. Installation or replacement above ground or underground storage of liquid petroleum products, liquefied petroleum gases, compressed natural gas, explosives or other regulated hazardous materials. 6. Gas rooms for dentist, doctors or veterinarians. 7. Generators with back -up diesel or other fuels. t/ 8. Large refrigeration systems. 9. Fuel cell systems. 10. Commercial pool systems. 11. Chemical Storage areas. 12. Flammable liquid storage. 13. Compressed Gases. 14. Dry cleaners. 15. Print Shops. 16. Auto Repair and Auto Body Shops. 17. Research and Development. For any additional information regarding this checklist, please contact Hazardous Materials Specialist, Santa Clara County Fire Department, at (408) 378 -4010. HasAlat 2011.doc revised 03107111 jt- Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408- 777 -3228 Fax: 408 - 777 -3333 CONTRACTOR SUBCONTRACTOR LRST JOB ADDRESS: fv / 0 v fcx, ,4,1 e. PERMIT # i y 12- a a'4 S OWNER'S NAME: i417° ie ,—t (- L L PHONE # 46)q'- -Tee— Y 71 I GENERAL CONTRACTOR: ,Vv V,, BUSINESS LICENSE # ADDRESS: IW O 2< CITY /ZIPCODE: " X'J 740 Z5� *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OILA FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OB'T'AINED A CITY OF CUPE ZTINO BUSINESS LICENSE. E am not using any subcontractors: Signature ??ease check applicable subcontractors and complete the following information: c9 Date 5VWL' f 6 // S ner / Contractor Signature f Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical o ���2 6 frr Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal i�"CGD 6,15" ele S f }F S Sheet Rock Tile 5VWL' f 6 // S ner / Contractor Signature f Date