B-2016-3193CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-3193
20620 HOMESTEAD RD CUPERTINO, CA 95014-0431 (326 10 066)
TILTON PACIFIC
CONSTRUCTION INC
ROCKLIN, CA 95677
OWNER'S NAME: SOBRATO INTERESTS 1 ETAL
DATE ISSUED: 03/08/2017
OWNER'S PHONE: 925-467-3187
PHONE NO: (916) 630-7200
LICENSED ONT TOR' DECLARATION
BUILDING PERMIT INFO:
License Class a Lie. #488531
Contractor TILTON PACIFIC CONSTRUCTION INC Date 03/31/2018
X BLDG —ELECT -PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH X RESIDENTIAL COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
TJ - PHARMACY WAITING AREA (50 S.F.) - SAFEWAY
I hereby affirm under penalty of perjury one of the following two declarations:
r. 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.
�I have and will maintain Worker's Compensation Insurance, as provided for by
,�'�-�9" Section 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $40000.00
permit is issued.
APPLICANT CERTIFICATION
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
326 10 066
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 Cupertino Municipal Code, Section 9.18.
180 DAYS FROM L ED INSPECTION.
Signature;-' i"� nate 03/08/2017
�T
OWNER -BUILDER DECLARATION
e: 03/08/201
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
RE -ROOFS:
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: 03/08/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
r. 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
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 & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issued.
maintain compliance with 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
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 Co' a Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.l'
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 03/08/2017
1 certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a 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
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 03/08/2017
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPIAENT DEPARTMENT .- BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3200 �B
TtN(408) 777-3228 • FAX (408) 777-333buiId1n'a(%,z�neriJno,.
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PRE -APPLICATION r_11'ES IF YES, PROVIDE COPY OF
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TOTAL VALUATION:
PLANNING ADPL 4 I-jN0 PLANNING APPROVAL LETMR
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By my signature below, 1 certify to each of thefollowing: I am the property owner or authorized agent lo act on 'he property owner's behalf, I have read this
application and the information I have provided is comet, I have read the Description of Work and verify it is accurate. I agree to comply with all. applicable local
ordinances and state laws re . lati",buildingeonstrtiql n' I authorize representatives of Cupertino. to enter the above -identified property for inspection purposes.
Signature ofApplicant/Agerft: ✓ Date;
SUPPLEMENTALIN5P RMATIOX REQUIRED
PLAN CHECK TYPE.,
ROUTJING SLTY
OVER -THE -COL N-=
BUIELDING PLAN".RFV1EW
New SIT) or Multifamily dwellings: Apply for demolition permit for
existing I'milding(s). Demolition permit is requiredprior-to issuance Of building
permit for new buildi ng.
El EXPRESS
Ci. 111-ANIN INTG PLAN'REVIEW
Commercial Bldgs: Provide a. completed Hazardous Materials Disclosure
IT'S7rANDARD
[J PTjau'c. WORKS
form if any Hazardous Materials are being used as part of this project.UUIGE
FIRE DEPT
COPY ofPlanningApproval Letter or Meeting with Planning, prior to
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s'_ub_mittal ofBuildivg Permit application.
RE
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B1dgApp_201Ldoc revised 06121/11
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: &d- 140rkq e S -c-
PERMIT #
OWNER'S NAME Sob
PHONE # '16'- G 3o - 7 ol6 C>
GENERAL CONTRACTOR: R.C1 Fi G C:C n S -1 •
BUSINESS LICENSE #
ADDRESS: G,tr,., e
CITY/ZIPCODE: e�kf
'Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) 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 Date
Please check applicable subcontractors and complete the following information:
6-13- 7
Owner / Contract ignature Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Landscaping
Lathing
Masonry
Painting / Wallpaper
SIC -C( -r-7 L I'Il° ',i vtfr ,^
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile_
6-13- 7
Owner / Contract ignature Date