B-2016-3288C�
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-3288
10300 TORRE AVE CUPERTINO, CA 95014-3202 (369 31 033)
PRO -EX
CONSTRUCTION INC
RANCHO CORDOVA,
CA 95670
OWNER'S NAME: CUPERTINO CITY OF
DATE ISSUED: 02/23/2017
OWNER'S PHONE: 408-777-3232
PHONE NO: (916) 868-2137
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class B Lic. #959719
Contractor PRO -EX CONSTRUCTION INC Date 10/31/2017
X BLDG _ELECT _PLUMB
MECH RESIDENTIAL X COMMERCIAL
I hereby affum 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:
1ST FLOOR T.I. - OFFICE (1025 S.F.) -CITY HALL/PUBLIC WORKS
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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
L
performance of the work for which this permit is issued.
,z! 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
Sq. Ft Floor Area:
Valuation: $15000.00
permit is issued.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
369 31 033
A (Tenant Improvements),B (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 EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations per the ertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
1
Signature Date 2/23/2017
Issued by: AUyAygnde
OWNER -BUILDER DECLARATION
Date: 02/23/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
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)
z. 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: 2/23/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS 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.
HAZARDOUS MATERIALS DISCLOSURE
z. 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 & Safety Code, Sections 25505,-25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
a. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked. rOwner
or authorized agent: .
APPLICANT CERTIFICATION
Date: 2123/2017
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097; Civ C.)
relating to building construction, and hereby authorize representatives of this city
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
ARCHITECT'S DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 2/23/2017
professional
CONSTRUCTION PERMIT APPLICATION Wlot(v
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 B
(408) 777-3228 - FAX (408) 777-3333 - building(W-cupertino.org
El NEW CONSTRUCTION FI ADDITION MX ALTERATION/TT M RFVTqT0W/T)_PV_PRI?ED npYr-TXTAT DYIPMT"r4i
PROJECT "Iss 1.0300 Torre Avenue
7APN# 369-31-033
OWNERNAME City of Cupertino
PHONE 408-777-3232
1 E-MAIL AlexA@cupertino.org
sTREETADDREss 10300 Torre Avenue
CITY, STATE, ZIP Cupertino, CA 95014
FAX
CONTACT NAME Alex Acenas, Public Works PM
PHONE 408-777-3232
E-mA'LAlexA@cupertino.org
STREET ADDRESS
10300 Torre Avenue
CITY, STATE, ZIP _T_
Cupertino, CA 9501 Z
FAX
❑ OWNER ❑ OWNER -BUILDER 13 owNERAGENT 13 CONTRACTOR 13CONTRACTOR AGENT 191 ARCHITECT 13 ENGiNEER 13 DEVELOPER 1:1 TENANT
CONTRACTOR NAME
LICENSE NUMBERLICENSE TYPE
BUS. LIC # �0
COMPANY NAME
E MAIL
FAX
STREETADDRESS16
ZZ
CITY, STATE, ZIP
PHONE
PHONE
ARcHITEcT/ENGINEERNAME Mark Bartos
LICENSE NUMBER C -24138
BUS, LIC #
cOmPANyNm,ffi Bartos Architecture
E -MAI' mb@bartosarchitecture.com
FAx
sTREETADDRFss 1730 South Amphlett Blvd., Ste. 225
CITY, STATE, ZIP San Mateo, CA 94402
PHONE 650-340-1221
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some electrice -17,Ire -alarm, mechanical, and fire sprinkler modifications which will
design build.
EXISTING USE
PROPOSED USE CONSTR_
TYPE
# STORIES
OFFICE
N/A
11-A
USE
TYPE
OCC.
SQ.FT.
VALUATION
EXISTG
AREA
NEW FLOOR
AREA NIA
I DEMO
AREA
.2
TOTAL
I NET AREA
BATHROOM
KITCHEN
OTHER
REMODELAREA
REMODELAREA
REMODELAREA
PORCH AREA
DECK AREA
GARAGE AREA: LJ DETACH
�
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT E]YES
SECOND STORY []YES
BEINGADDED? ®NO
ADDITION? JENO,
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES=
BY:
TOT AL VALUATION:
PLANNING APPL # NO PLANNING APPROVAL LETTER
EICHLER HOME? NO
I
, (W
By my signature below, I certify to each of the following: I am the property owner or authorized agent to aon the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the I)escription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatlq- c Puctio . /rr=_tiV es of Cupertino to enter the above -identified property for inspection purposes.
7 �b,Iding
12/16/16
Signature of Applicant/Agent: Date:
SUPPLEMENYAL INY�' TION REQUIRED
PLAN CHECK TRPS
ROUTING SUr
0 OVER-THE-COUNTER
❑ BU"ING 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.
11 EXPRESS
'n PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
1D STANDARD
❑ PUBLIC WORKS
form if any Hazardous, Materials are being used as part of this project.
171 LARGE
FIREDEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
0 MAJOR
❑ SANITARY SEWER DISTRICT
submittal of Building Pen -nit application.
❑ ENVIRONMENTAL HEALTH
BIdgApp_2011.doc revised 06121111