B-2016-3326CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
19409 STEVENS CREEK BLVD STE 110 CUPERTINO, CA 95014 (316 20 112)
OWNER'S NAME: MAIN STREET CUPERTINO
OWNER'S PHONE: 310-577-7171
LICENSED CONTRACTOR'S DECLARATION
License Class 13 Lic. # 79 7691
Contractor A I ON TR TION INCDate 10/31/2018
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:
L 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
ormance of the work for which this permit is issued.
2.- ve and will maintain Worker's Compensation Insurance, as provided for by
( ction 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 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. ity in consequence of the granting of this permit.
Additionally, the applicafunderstands and will comply with all non -point
source regulations p6Vhe Cupertino,MW*ipal Code, Seen 9.18.
Signature 4/5/2017
CONTRACTOR:PERMIT NO: B-2016-3326
ALEGIS
CONSTRUCTION INC
PORTLAND, OR 97223
DATE ISSUED: 04/05/2017
PHONE NO: (20 6) 724-0385
BUILDING PERMIT INFO:
BLDG —ELECT —PLUMB
MECH _ RESIDENTIAL X COMMERCIAL
JOB DESCRIPTION:
SUITE 110 PRESSED JUICERY;TENANT IMPROVEMENT (665 SQ FT)
Sq. Ft Floor Area: ( Valuation: $92000.00
APN Number: Occupancy Type: .
316 20 112 A (Tenant Improvements),M (Tenant Improvements)
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: AbbL, end
Date: 04/05/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the RF ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is
t. 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
contractors to construct the project (Sec.7044, Business & Professions Code).
hereby affirm under penalty of perjury one of the following three 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.
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.
s. 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
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, 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 4/5/2017
Signature ofAl
Date: 4/5/2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I 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 I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air uality Management District I
will maintain compliance with the Cuper ' u cipal Code, Chapter 9.12 and
the Health & Safety Code, Sec ' ns 25 524533; and 5534.
Owner or authorized age C
Date: 4/5/2017
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
3, - (�
CONSTRUCTION PERMIT APPL ATION
COMMUNITY DEVELOPMENT DEPARTMENT - Bij— TING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-32j5
CUPERTINO (408) 777-3228 - FAX (408) 777-.3333 - buffdingCa�cuperfino.oLq
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EMSTING USE PROPOSED USE CONSTR.T1
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AREA AREA AREA 17%
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PRE -APPLICATION 1-1 YES IF YES.PROVIDE COPY OF ISTHESLDGAN
ONO PLANMNOAPPROVALLETTER EICHLERHOME? [ANO
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By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
have
application and the information e Is come
I h .0. read the Description oflVork and verify it is accurate. I agree to comply with all applicable local,
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ordinances and state taws on
l; "ng on. la orize representatives of enter th above -idea ed property for inspection purposes.
Signature ofApplicantf.Agent, Date: yl0-1 1.4,
SUPPLEMENTAL INFORMATION REQUIRED P e' CHECKTYPE 901i'TINGSUP
New SFD or Multifamily dwellings: Apply for demolition permit fori� o1'ERaltF CCOLn RUMMG MA5 REV IF -IV
existing building(s). Demolition permit is required prior to issuance ol'building
permit for new building. 0 EXPRESS 1"'MMG PLAN REVI EXV
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure V STANDARD
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Torinifany flazardDUS Materials are being used as part of this project.
1`1 LARGE FIREDEFT
Copy of Planning Approval Letter or Nfeeting with Planning prior to
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submittal of Building Permit application.
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STATE OF CALIFORNIA
MECHANICAL
CFC_NR(`i_M!"u111_C ro--i A n.m.,
CERTIFICATE OF INSTALLATION
CALIFORNIA ENERGY COMMISSION -Wp�
NRCI-MCH-01-E
Mechanical
(Page 1 of 2)
Project Name: IZLS �, `
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Enforcement � en Permit Number:
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Project Address:
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City:
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with chief responsibility for construction shall prepare and sign the Installation Certificate document(s) for the entire
construction.
A. GENERAL INFORMATION
DATE OF BUILDING PERMIT
In the table below identify all applicable construction documents that specify the features, materials, components,
manufactured devices, or system performance diagnostic results required for the scope of responsibility for this Installation
Certificate.
BUILDING TYPE
Applicable Sheets or Pages, Tables, Schedules, etc.
PHASE OF CONSTRUCTION Tee (10t -I►vx _mj `j C-M-RTt--� l
If more than one person has responsibility for building construction, each person shall prepare and sign an Installation
Certificate document applicable to the portion of construction for which they are responsible; alternatively, the person
with chief responsibility for construction shall prepare and sign the Installation Certificate document(s) for the entire
construction.
B. SCOPE OF RESPONSIBILITY
Date of approval by the enforcement agency of the Certificate of Compliance that provides the specifications for this
Installation Certificate.
In the table below identify all applicable construction documents that specify the features, materials, components,
manufactured devices, or system performance diagnostic results required for the scope of responsibility for this Installation
Certificate.
Document Title or Description
Applicable Sheets or Pages, Tables, Schedules, etc.
Date Approved By
the Enforcement
Agency
qq l
L
i ee T 5 M
2017
CA Building Energy Efficiency Standards - 2013 Nonresidential Compliance May 2015
STATE OF CALIFORNIA
MECHANICAL
CEC-NRCI-MCH11-P IR—iearl 0s:1.i q�
CERTIFICATE OF INSTALLATION
cAUFCIRNIA ENERGY COMMISSION --MP-
NRCI-MCH-01-E
Mechanical
Mechanical
(Page 2 of 2)
Project Name:
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TEnfol�mm=n-��j��SSp Permit Number:
ProjectAddress: ' ' 1 _ t �y �f�S/ �'l C'iY I VCl '
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DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
I. I certify that this Certificate of Installation documentation is accurate and complete.
Documentation Author Name:
(A R (t-- 1 � t U ;..-+7
Documentatio gnat
Documentation Author Company Name:
Date Signed:
Address:'&1 ':LTxCiu-?`i'r+cl Lir.
.� p .
CEA/ HERS Certification Identification (if applicable):
City/State/Zip: PP 1115 4-er CA '�15)7_ 3
Phon
RESPONSIBLE PERSON'S DECLARATION STATEMENT
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Installation is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code in the applicable classification to accept responsibility for the
system design, construction, or installation of features, materials, components, or manufactured devices for the scope of work
identified on this Certificate of Installation and attest to the declarations in this statement (responsible builder/installer),
otherwise I am an authorized representative of the responsible builder/installer.
3. The constructed or installed features, materials, components or manufactured devices (the installation) identified on this
Certificate of Installation conforms to all applicable codes and regulations, and the installation conforms to the requirements
given on the plans and specifications approved by the enforcement agency.
4. 1 reviewed a copy of the Certificate of Compliance approved by the enforcement agency that identifies the specific requirements
for the scope of construction or installation identified on this Certificate of Installation, and I have ensured that the requirements
that apply to the construction or installation have been met.
5. 1 will ensure that a completed signed copy of this Certificate of Installation shall be posted, or made available with the building
permit(s) issued for the building, and made available to the enforcement agency for all applicable inspections. I understand that a
completed signed copy of this Certificate of Installation is required to be included with the documentation the builder provides to
the building owner at occupancy.
Responsible Builder/Installer Na
.1U14�+;LT
ResponfiR"u' Inst
Company Name: (Installing ubcontractororGeneral Contractor or Builder/Owner)
WtL _ ^ 1e�h�.��c� i
Position With Compan (Title):
ce C, ,
Address: b,, I 1i ��/��� � �
I cla
CSLB License: } `
City/state/Zip- '
Phone 7ft DateSigned:-
ouiiuiiig ciiergy crriclency btanaaras - 2013 Nonresidential Compliance May 2015