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B-2017-0172 CITY OF CUPERTINO BUILDING PERMIT BUIL DING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0172 23500 CRISTO REY DR UNIT 405E CUPERTINO,CA 95014-6531(342 53 154) BAY AREA ENTERPRISE SAN JOSE,CA 95148 OWNER'S NAME: SUMMIT ROGER K TRUSTEE&ET AL DATE ISSUED:04/06/2017 OWNER'S PHONE:650-537-1523 PHONE NO:(408)238-5043 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#817817 Contractor BAY AREA ENTERPRISE Date 03/31/2019 X BLDG X 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: COMBINE UNITS 405E(PRIMARY)&403E-(N)LIGHTS 12,(N) I hereby affirm under penalty of perjury one of the following two declarations: OUTLETS 2;REMODEL/CONVERT TO 1. I have and will maintain a certificate of consent to self-insure for Worker's (N)HALLWAY,(N)CLOSET(100 S.F.)(2 PERMITS FOR COMBINING Compensation,as provided for by Section 3700 of the Labor Code,for the UNITS B-2017-0404) /performance of the work for which this permit is issued. 722.C- 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:$40500.00 APPLICANICERTIEICATION 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 342 53 154 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 stands andce the hg othis WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupe•in9.Municipal Code,Section 9.18. 180 DAYS FROM LAS SPECTION. Signature Date 04/06/2017 Issued by:MELI SA Date:04/06/2017 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 roofmg 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:04/06/2017 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 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 s. 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 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 Munici Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sec' 5 2553 and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent:/ CCS APPLICANT CERTIFICATION Date:04/06/2017 ',G�_ 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 there 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 permit 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 shall be used as public records. Licensed Signature Date 04/06/2017 Professional , 7 CONST''*:UCTlOF "RE MIT' APDL CATIO --- . .: COMMUNITY DEVELOPMENT DEPARTMENT a BUILDING DIVISION :i ksr ; :_ 'i0300 TORRE AVENUE o CUPERTINO,CA 950•I4-3255 C;t3 PEt $I6�3 i (408)777-3228 4 FAX(408)777-3333 o buildinac cupertino.ora -5_,16(--q.. r } ❑NEW CONSTRUCTIONR I V T ❑ ADDITION ►.' LTL•RATION/TI 0 REVISION/DEC>rItR1~D ORIGINAL PERMIT t! PROJECrADDRESS N .yM Mill 00 CIES R, tlwil- ' , ( k, OWNER NAME _�7 -n^/ ? E-MAIL ik4. ^:V'tA?A : IvO'b�J``j gu.,1411ln,1T - 1 t® ®- 39- ir2.3 Feecf e rvtaIA.4434, RIC•G6ct STREET ADDRESS A CITY,STATE.ZIP �� FAA 13'3 ib L.e_nnax 4.)ti7 f e)c I' r14,11S' t. 611' ? CONTACT NAME PHONE E-M IL C.►-et *-- •y- t,, --2.3ei -WS 03 %-e -ec7413corm • STREET ADDRESS CITY,STATE,ZIP FAX • ; Zile) Pna.tot At tat el Sa— gt4- ri 51cAe El OWNER 0 OWNERDOMLDER, El OWNER AGENT EC CONTRACTOR 0 CONTRACTOR AGENT El AucurrECT ❑ENGINEER 0 DEVELOPER ❑TENANT ' CONTRACTOR NAME E.7'Z4P. LICENSE NUMBER LICENSE TYPE BUS.L/C 1E - L :I7 .I COMPANY1 LMEE-MAIL „ FAX B Q ii, 1O'roe,0... • 4 ort't ? i nee,s .,s '-_C Q it[ STR.EETADDREtSS CITY STATE,ZIP PHO - :( ,yt ARCHTIECTIENGINEER NAME -LICENSE NUMBER RUE.LIC C • • COMPANY NAME E-MAIL FAX STREb-TADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK tit etr-oe it U.RA: (-S I7,05E 4 e1Q3E eci , Hai/ ite r-E l, : • -, , /W 4M PetwgCped .,,- q--/Vea P--/----i7,- - J • f EXISTING USE PROPOSED USE CONSTR.TYPE S STORIES USE TYPE OCC., SQ.FT. VALUATION CS) IIXISrG ' NEW FLOOR DEMO 'rOTAl: ,` AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER i REMODEL AREA REMODEL AREA REMODEL AREA E PORCH AREA DECK AREA TOTAL DECKWORCL1 AREA GARAGE AREA: IR DETACH O ATEACH ri DWELLING UNnS: ISA SECOND UNIT OYES SECOND STORY ©YES BEING ADDED? ONO ADDITION? ONO PRE-APPLICATION AYES IF YES,PROVIDE COPY OF 1STHE BLOGAN DYES REt• D: TOTAL VALUATION: PLANNING APPLS LINO 'PLANNING APPROVAL LETTER EICIILER HOME? ONO 0 OM ✓'"".-- i By my signature below,I certify to each of the follow'ig; I am the property owner or uuth rized a_ent'act oto the property owner's behalf. Ihave gad this � application and the information I have provided is c. Cr. I hay - d the Description of Work and verity it is accurate. I agree to comply-with all applicable local ordinances and state laws relating to building con)i.ction. I a,forize representatives of Cupertino to enter the above-identif-d property or inspection urposes. Signature of Applicant/Agent: Date: / i * -SUPPLEMENT• INFORMATION REQUIRED . PLAN CHECK TYPE ROUTING SLIP .. _New SPD or Multifamily dwellings: Apply for demolition permit for p OVER THE COUNTER 0 WILDING PLAN REVIEW • existing building(s). Demolition permit is required prior to issuance of building . • • permit for new building. ❑ EXPRESS . IDI PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD D PUBLIC WORKS • ; form if any Hazardous Materials are being used as part of this project. p LARGE 0 TIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to o aBuox ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. - - 0 ENVIRONMENTAL HEALTH BldgAtpp 201 Lilac revised 06/21/11 Recorded at the request of and mail to: Feist (Name) 2110 Mangin Way (Address) San Jose, CA 95148 23599901 % - zoo _ 9eG Regina Alcomendras Santa Clara County — Clerk—Recorder 03/10/2017 09:53 AM Titles: 1 Pages: 6 Fees: $40.00 Taxes: $0 Total: $40.00 COVENANT AND AGREEMENT TO HOLD PROPERTY AS ONE PARCEL The undersigned hereby certify that we are the owners of real property located in the Cityof Cupertino, State of California that is legally described (as. follows) (on the attached exhibit(s) ): LOTS(S) BLOCK TRACT See attached legal description Exhibit A LOTS(S) BLOCK TRACT LOTS(S) BLOCK TRACT 342-53-152 & 342-53-154 v�loy _ as recorded in Book _N273 / M928 . Page _849 / 0672 Records of Santa Clara County. This property is located at and is known by the following ADDRESS: <23,500 "Cristo Rey Drive #403E and -#405E, Cupertino -CA 95014 , We hereby agree and covenant w-itb-the City of Cupertino that the above legally described real property shall be held as one parcel and no portion shall be sold separately. This covenant and agreement is executed for the purpose of creating a single building site (and) _create an opening between the units to combine them, as regulated by Section 12.03 (and) of the Cupertino Municipal Code. Upon the sale of either of the units/ parcels the required fire partition shall be permitted and constructed per the requirements of Sections 420 and 709 of the 2010 California Building Code. This covenant and agreement shall run with all of the above described land and shall be binding upon ourselves, and future owners, encumbrances, their successors, heirs or assignees and shall continue in effect until released by the authority of the Superintendent of Building of the City of Cupertino upon submittal of request, applicable fees and evidence that this Covenant and agreement is no longer required by law. 46 Howard and Sally Peters l` Owner's Name oW0V`iii. A Pi ORDER NO.: 0611018135 EXHIBIT A The land referred to is situated in the County of Santa Clara, City of Cupertino, State of California, and is described as follows: A SUBLEASEHOLD TESTATE as created by that certain document entitled "Memorandum of Occupancy Agreement" dated November 3, 1993, made by and between Rancho San Antonio Housing Corporation, a California nonprofit corporation and Forum Cupertino Lifecare Inc., an Indiana corporation, as Lessor(s), and Forum Lifecare, Inc., as Lessee, for the term and upon the terms and conditions contained in said lease. Said Memorandum recorded January 28, 1994, in Book N273 of Official Records, Page 0849, Instrument Number 12332779. NOTE: The sub -lessee's interest under said lease, From Roger K. Summit, Trustee and Virginia M. Summit, Trustee, who acquired title as Virginia B. Summit, Trustee of the Summit Family Trust dated March 17, 2000 To Roger K. Summit, Trustee and Virginia M. Summit, Trustee of the Summit Family Trust dated March 17, 2000 Recorded January 8, 2016 in Official Records under Recorder's Serial Number 23191788 Return to 23500 Cristo Rey Drive, Cupertino, CA 95014 Note: Title to the Sublessor's interest at the date hereof is vested in Rancho San Antonio Retirement Housing Corporation, a California non-profit corporation. Said Subleasehold Estate being derived from that certain Ground Lease dated October 1, 1987, made by and between The Roman Catholic Bishop of San Jose, a corporation sole, as Lessor and Forum Lifecare Inc., an Indiana Corporation, as Lessee, for the term and upon the terms and conditions contained in said lease, the original thereof recorded December 11, 1987 in Book K387 of Official Records, page 1708. And as modified by those certain agreements recorded October 12, 1989 as Instrument No. 10285837 and recorded December 15, 1989 as Instrument No. 10360135. The Lessee's interest under said Ground Lease was assigned to Rancho San Antonio Retirement Housing Corporation, a California non-profit corporation by that certain assignment recorded December 19, 1989 as Instrument No. 10375527. NOTE: Title to the Lessor's interest at the date hereof is vested in The Roman Catholic Bishop of San Jose, a corporation sole. in and to the following: PARCEL ONE: Page 1 of 3 RESIDENTIAL UNIT 403E, as shown on that certain Tax Assessment Plan of the Forum at Rancho San Antonio, filed May 27, 1998 in Book 32 of Assessment District Maps, at pages 10 through 22, Santa Clara County Records. Said Unit being situated on the following described land: A portion of that certain 473 acre tract of land conveyed to The Roman Catholic Archbishop of San Francisco by deed recorded May 13, 1920, in Book 517 of Deeds, page 40, Santa Clara County Records, and being more particularly described as follows: BEGINNING at the Southeasterly corner of Parcel 1D as said parcel 'is described in the final Order of Condemnation No. P8390 had in the Superior Court of the State of California, in and for the County of Santa Clara, Palo Alto Branch, a copy of the Instrument for which decree was recorded September 7, 1975 in Book 7096 Official Records, page 183, Santa Clara County Records, said corner being in the Northwesterly line of that certain 37.92 acre parcel of land conveyed to Catholic Foreign Mission Society of America by Deed recorded July 29, 1929 in Book 478 of Official Records, page 11, Santa Clara County Records; thence from said POINT OF BEGINNING along the general Southwesterly lines of said Parcel 1D, the ten following courses and distances: North 461 47' 48" West 37.36 feet, North 770 33' 00" West 181.89 feet, North 561 49'44" West 166.81 feet, North 501 0745" West 169.97 feet, North 471 45'40" West 493.95 feet, North 500 48'38" West 200.26 feet, North 460 49'49" West 302.17 feet, North 610 04' 48" West 100.85 feet, North 530 33' 56" West 492.46 feet and North 580, 04' 03" West 151.88 feet to the Northeasterly corner of :Parcel 1E, as said Last named parcel was described in said Final Order of Condemnation; thence along the Southeasterly line of said Parcel 1E South 221 15' 34" West 155.09 feet to the most Southerly corner of said Parcel 1E, thence along the Southwesterly line of said 'Parcel 1E North 650 58'47" West 40.87 feet, more or less, to the intersection thereof with the centerline of the paved roadway leading to Saint Joseph's Seminary; thence along said centerline as follows: South 050 02' 20" West 159.41 feet, South 010 27' 23" West 100.00 feet, South 010 16' 37" East 100.00 feet, South 03° 02'54" East 67.84 feet, Southerly along an arc of a tangent curve to the left with a radius of 400.00 feet through a central angle of 370 55' 43" an arc distance of 264.79 feet, tangent to the preceding curve South 400 58' 37" East 31.47 feet, Southeasterly along an arc of a tangent curve to the left with a radius of 700.00 feet through a central angle of 121 45' 00" an arc distance of 155.77 feet, tangent to the preceding curve South 530 43' 37" East 189.70 feet and Southeasterly along an arc of a tangent curve to the right with a radius of 600.00 feet; through a central angle of 200 26' 20" an arc distance of 214.04 feet; thence leaving said centerline North 560 42' 43" East 25.00 feet; thence at right angles South 330 17' 17" East 1392.84 feet, more or less, to a point in a Northerly line of that certain Parcel of Land designated as Parcel A conveyed to County of Santa Clara, by deed recorded October 11, 1977 in Book D197 Official Records, page 696, Santa Clara County Records and shown as a 127.884 acre parcel of land upon that certain Record of Survey filed October 2, 1979, in Book 450 of Maps, page 41, Santa Clara County Records, said point being distant along said Northerly line South 810 13' 03" West 214.00 feet from the most Northeasterly corner of said Parcel A; thence along said Northerly line North 810 13' 03" East 214.00 feet to said most Northeasterly corner of said Parcel A; thence along the general Easterly lines of said Parcel A; as shown on said Record of Survey, the four following courses and distances: South 120 55' 09" East 245.07 feet, South 090 25' 07" East 745.77 feet, North 750 01' 33" 'East 241.01 feet and South 301 13' 39" East 196.71 feet to the most Easterly corner of said Parcel A; thence along the Northeasterly prolongation of the Southeasterly Line of said Parcel A, North 510 02' 05" East 477.94 feet, more or less, to the intersection thereof with the Southerly line of said 37.92 acre parcel; thence along said Southerly line North 83° 53' 21" West 118.42 feet; thence along the Southwesterly and Northwesterly lines of said 37.92 acre Page 2 of 3 ORDER NO.: 0611018134 . EXHIBIT A The land referredto is situated in the County of Santa Clara, City of Cupertino, State of California, and is described as follows: A SUBLEASEHOLD ESTATE as created by that certain document entitled "Memorandum of Occupancy Agreement" dated August 3, 1993, made by and between Rancho San Antonio Housing Corporation, a California nonprofit corporation and Forum Cupertino Lifecare Inc., an Indiana corporation, as Lessor(s), and Forum Lifecare, Inc., as Lessee, for the term and upon the terms and conditions contained in said lease. Said Memorandum recorded August 6, 1993, in Book M928 of Official Records, Page 0672, Instrument Number 12036364. NOTE: The sub -lessee's interest under said lease, From Barbara M. Isola, Trustee of the Barbara M. Isola Trust dated October 16, 1987 To Roger K. Summit, Trustee and Virginia M. Summit, Trustee of the Summit Family Trust dated. March 17, 2000 Recorded January 8, 2016 in Official Records under Recorder's Serial Number 23193019 of Official Records Return to 23500 Cristo Rey Drive, Cupertino, CA 95014 Note: Title to the Sublessor's interest at the date hereof is vested in Rancho San Antonio Retirement Housing Corporation, a California non-profit corporation. Said Subleasehold Estate being derived from that certain Ground Lease dated October 1, 1987, made by and between The Roman Catholic Bishop of San Jose, a corporation sole, as Lessor and Forum Lifecare Inc., an Indiana Corporation, as Lessee, for the term and upon the terms and conditions contained in said lease, the original thereof recorded December 11, 1987 in Book K387 of Official Records, page 1708. And as modified by those certain agreements recorded October 12, 1989 as Instrument No. 10285837 and recorded December 15, 1989 as Instrument No. 10360135. The Lessee's interest under said Ground Lease was assigned to Rancho San Antonio Retirement Housing Corporation, a California non-profit corporation by that certain assignment recorded December 19, 1989 as Instrument No. 10375527. NOTE: Title to the Lessor's interest at the date hereof is vested in The Roman Catholic Bishop of San Jose, a corporation sole. in and to the following: PARCEL ONE: Page 1 of 3 RESIDENTIAL UNIT 405E, as shown on that certain Tax Assessment Plan of the Forum at Rancho San Antonio, filed May 27, 1998 in Book 32 of Assessment District Maps, at pages 10 through 22, Santa Clara County Records. Said Unit being situated on the following described land: A portion of that certain 473 acre tract of land conveyed to The Roman Catholic Archbishop of San Francisco by deed recorded May 13, 1920, in Book 517 of Deeds, page 40, Santa Clara County Records, and being more particularly described as follows: BEGINNING at the Southeasterly corner of Parcel 1D as said parcel is described in the final Order of Condemnation No. P8390 had in the Superior Court of the State of California, in and for the County of Santa Clara, Palo Alto Branch, a copy of the Instrument for which decree was recorded September 7, 1975 in Book 7096 Official Records, page 183, Santa Clara County Records, said corner being in the Northwesterly Line of that certain 37.92 acre parcel of land conveyed to Catholic Foreign Mission Society of America by Deed recorded July 29, 1929 in Book 478 of Official Records, page 11, Santa Clara County Records; thence from said POINT OF BEGINNING along the general Southwesterly lines of said Parcel 1D, the ten following courses and distances: North 4614748" West 37.36 feet, North 770 33' 00" West 1181.89 feet, North 560 49'44" West 166.81 feet, North 500 0745" West 169.97 feet, North 470 45'40" 'West 493.95 feet, North 500 48' 38" West 200.26 feet, North 460 49' 49" West 302.17 feet, North 610 04'48" West 100.85 feet, North 530 33' 56" West 492.46 feet and North 580'04, 03" West 151.88 feet to the Northeasterly corner of Parcel 1E, as said last named parcel was described in said Final Order of Condemnation; thence along the Southeasterly line of said Parcel 1E South 220 15' 34" West 155.09 feet to the most:Southerly corner of said Parcel 1E, thence along the Southwesterly line of said Parcel 1E North 650 58'47" West 40.87 feet, more or less, to the intersection thereof with the centerline of the paved roadway leading to Saint Joseph's Seminary; thence along said centerline as follows: South 050 02' 20" West 159.41 feet, South 010 27' 23" West 100.00 feet, South 010 16' 37" East 100.00 feet, South 030 02' 54" East 67.84 feet, Southerly along an arc of a tangent curve to the left with a radius of 400.00 feet through a central angle of 370 55' 43" an arc distance of 264.79 feet, tangent to the preceding curve South 400 58' 37" East 31.47 feet, Southeasterly along an arc of a tangent curve to the left with a radius of 700.00 feet through a central angle of 120 45' 00" an arc distance of 155.77 feet, tangent to the preceding curve South 530 43' 37" East 189.70 feet and Southeasterly along an arc of a tangent curve to the right with a radius of 600.00 feet; through a central angle of 200 26' 20" an arc distance of 214.04 feet; thence leaving said centerline North 560 42' 43" East 25..00 feet; thence at right angles South 330 17' 17" East 1392.84 feet, more or less, to a point in a Northerly line of that certain Parcel of Land designated as Parcel A conveyed to County of Santa Clara, by deed recorded October 11, 1977 in Book D197 Official Records, page 696, Santa Clara County Records and shown as a 127.884 acre parcel of land upon that certain Record of Survey filed October 2, 1979, in Book 450 of Maps, page 41, Santa Clara County Records, said point being distant along said Northerly line South 810 13' 03 West 214.00 feet from the most Northeasterly corner of said Parcel A; thence along said Northerly line North 810 13' 03" East 214.00 feet to said most Northeasterly corner of said Parcel A; thence along the general Easterly lines of said Parcel A; as shown on said -Record of Survey, the four following courses and distances: South 120 55' 09" East 245.07 feet, 'South 090 25' 07" East 745.77 feet, North 750 01' 33" East 241.01 feet and South 300 13' 39 East 196.71 feet to the most Easterly corner of said Parcel A; thence along the Northeasterly prolongation of the Southeasterly line of said Parcel A, North 510 02' 05" East 477.94 feet, more or less, to the intersection thereof with the Southerly line of said 37.92 acre parcel; thence along said Southerly line North 830 53' 21" West 118.42 feet; thence along the Southwesterly and Northwesterly lines of said 37.92 acre Page 2 of 3 TM i k 'S p✓, CALIFORNIA • •WLEDGMENT CIVIL CODE § 1189 a a�. _a4_ s��� .ac_a s�'v�ai' a Ca�cGcACr.-a`� .a`..a�� �s a�� a ai.a�c.a�•.cac_a _ate .-�.�� _a.��� � � �C_a4_ve A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of Califpmia ) Coun of av c On Q4/y- before me, F Iio e, lJ Datb H re Insert Name and Ale of the ffi er personally appeared —p Name(s) of Signer(s) t who provedto me on tIkebasis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their, authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. PAULINC KUOISOVA Commission #f 2055839 L I Notary Public California a Signatures Santa Clara County Signature of Notary Public M Comm. E irts Jan 25,2018t Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an un . ntended doeQment. tie Description of Attached D#cumentIr�U �1 y_ J Title or Type of Do cu entf ! i Document Date:t Number of Pages: Signer(s) Other ( an Named Above: % / /4— Ca Signer's am ClainI" e g , Signer's Name: -jam ��'[�d'� Signer's Name: ❑ Corporate Officer — Title(s): ❑ Corporate Officer — Ti le(s): ❑ artner — ❑ Limited ❑ General ❑ Paftner — ❑ Limite . ❑ General ©'Individual) ❑ Attorney in Fact EVIndividual ❑ Attorney in Fact El Trustee ❑ Guardian or Conservator ❑ Trustee ❑ Guardian or Conservator ❑ Other: ❑ Other: Signer Is Representing: Signer Is Representing: ©2014 National Notary Association • www.NationaiNotary.org • 1 -800 -US NOTARY (1-800-876-6827) Item #5907 T�'S7ING1t�GIN�RS; INS: Date: _ i r DSA File. _ D A Prnject No.: GSHPD No.: _ Project Name: CSC? E1e _._ Permit / SF App. #: -1_Z _.. _ - row Code: Address: / G? �. _ - _�..�_� ____ _.._ ._�. _ Start 'rime: _ o City - Requested Requested by: Hours: Reimrted to: of:44_ _ EPDXIED DkLS -125 EPDXIED ANCHORS - 126 ❑ EXPANSION ANCHORS 12 (Witnessed the drilling of holes of proper diameter and depth. or f„ Q Inspected predrilled holes for proper diameter and depth. Expiration Date of Epoxy f JI'1� Observed the cleaning of holes and the injection of . /<i.t.�®►,, r __. _ epoxy. or the insertion of epoxy capsules. Witnessed the proper insertion of: Qty. Bar #/ Type --Length, Embed,-- Location Dia, in. in. in. _+. Re arks/ Notes: Type 1 Do not tye �7fre workwas sr ,r not inspected in ae c ordanc< with the Building Department or I).SA or O,SIIPD approved documents. The work inspected met El did not meet the requirements o the Building Department or DSA orO.W/P/I) appravecf documents Js r�c-�Cr! us nnfed fr:t<rrfot srrnrpling Q t,ws� f was not �N/A trerfivnned in accordance with the Building i?e/rariment of C.)SA ar OSffl'D approvers 11ocloptepit.S. 1 )rratt�int, s Darted � �.J -- YXcity [l County F1 Shop C'Witication # Nati: nspcclor: �e�:cived Date. ------------ I:wporAit,, Offitre -. 281 i l r-IoaI } :n Suva t - Sari E ean<Srct. C:aiiforn.,a 94571 1 ! B3 } AX 00' 0 t3 34 yy�,w Tes�na-E�14ft+�a.cotts SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(alcupertino.org PERl)'IIT CANNOT BE FINAI�ED UNTIL TFIIS CERTIFICATE ITA.S BEEN COMPETED; SIGNED_ "AND °RETURNED TO THEBUILDING DIVISION' � j PURPOSE This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2016 CRC Section R314; R315,2016 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314, R315, and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE ALARM CO ALAR_ M Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) — (Smoke alarms shall not be located within 3 feet of bathroom door) X X On every level of a dwelling unit including basements and habitable attics X X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms specified below have been tested and are operational, as of the date signed below. j Address: 27 �ZF1�12 4:�7x/ �—y_d R/L Specify Number of Alarms: Smoke Alarms: Permit No (f z r,,n --©( ) Z ;# Carbon Monoxide Detectors: I ha VP. rp,)d Anil ansa to rmmnly with tha t.— -4 rnn i;t; o _, ' ft' ..f- 1 ..,. — Ov n r (or Owner Agent's) Name: g Ittu ....... Con or Name: ,.--- Signature...................................................................... Lic.#........................................ Date:................... Smoke mid CO form.doc revised 01/10%=017 CUPERTINO Owner Name Address WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org 4') ..,_-7 0'1't r i Permit No_) e- 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. IV No Go to Question 2. 2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. ❑ The licensed plumber's certification has been provided to the Building Division. Skip the rest of the form and sign bottom of form. F) No Go to Question 3. 3. Is water service permanently disconnected for your building? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. No Go to Question 4. 4. Is your real property built and available for use or occupancy on or before January 1, 1994? No My real property is built and available for use or occupancy after January 1, 1994. Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. ❑ Yes My real property is built and available for use or occupancy on or before January 1, 1994. Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign bottom of form.. Please check ONE of the following: My property is a single-family residential real property. See Civil Code Section 1101.4. On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non- compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements). ❑ My property is a multifamily residential real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). ❑ My property is a commercial real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and that the water-conservin umbing fixtures comply with the requirements as indicated in the table on the following naee. I Owner or Owner Agent's Signature: / C/ Date: % —_5; / � I Upon completing and signing this Certi—fic�please return it to the Building Division in order to final your building permit. SB40 7 2015. doe revised 01/05117 3MTM Fire Barrier Moldable Putty Pads MPP+ FIRE BARRIER SMOKE SEAL �P4a L� IIII.°VIII ���, al;a.1 eet, TO x Fre Protection Meets Optional L Requirements 1. Product Description WALLOPENING SOUNDBARRIER 3M`' Fire Barrier Moldable Putty Pads MPP+ are a one -part, ready -to -use, intumescent wall -opening protective. When TO 2 o y52 x properly applied to the back of electrical outlet boxes, 3M`' Fire Barrier Moldable Putty Pads MPP+ help control the spread Fre Prote lien m STC 53 -Ra ed Wall Assembl of fire, smoke and noxious gases through fire -restive walls and partitions. Installed in accordance with the UL wall -opening protective listing (UL Category CLIV), the product helps achieve up to 2 -hour ratings in a variety of wall constructions. 3W Fire Barrier Moldable Putty Pads MPP+ can effectively provide protection for back-to-back electrical boxes. r p A 3W Fire Barrier Moldable Putty Pads MPP+ are also used as a firestop material in through -penetration firestop systems. r IVI 3W Fire Barrier Moldable Putty Pads MPP+ help to maintain a firestop penetration seal for up to 4 hours. 3M- Fire APPROVED Barrier Moldable Putty Pads MPP+ exhibit excellent adhesion to a full range of construction substrates and penetrants. The ads are easily molded b hand no mixing required). In addition to its fire-resistant properties, the 1/10th in. 2 54mm SUBJECTSAWA HE COODIT ONS TROF 11ONAPPROVAL p Y Y ( g q )• p p ( ) AsnwALL&FLooRPENETRnnoN thick pads have airborne sound reduction characteristics which helps minimize sound transmission through assemblies FIRESTOP WHEN INSTALLED AS DESCRIBED requiring an STC rating. N THE CURRENT A VAL GUIOEFT} E FMRc Color: 0 Dark Red CiN SSIN Product Features��� U� • Firestop tested up to 4 hours in • Excellent adhesion accordance with ASTM E 814 • Re-enterable/repairable LISTED WALL OPENING PROTECTIVE (UL 1479) & CAN/ULC-5115 • Halogen -free and solvent -free FILL, VOID OR CAVITY MATERIAL FIRE RESISTANCE MATERIALS CLASSIFICATION SEE UL FIRE m �'""'"1 • Wall opening protective tested up to • Excellent aging properties 90G9 RESISTANCE DIRECTORY qti zwyQ t 2 hours in accordance with UL 263 • Low VOC 90G9 °° • Provides draft and cold smoke seal • Will not dry out or crumble �pSSIf/F AN�� "�^°'"�'°" �� " • Pliable and conformable—molds • Red color widely recognized as sfer* �' U G easily into required shape a fire protective product • Helps reduce noise tran FILL, VOID, OR CAVITY 4 in. x 8 in. (101.6mm x 203.3mm), Meets the intent ofLEED® VOC regulations—helps reduce the quantity of indoor air FOR USE IN THROUGH-PENETRAWN 7 in. x 7 in. (177.8mm x 177.8mm) and contaminants that may be odorous, irritating and harmful to the comfort and well-being FIRESTOP SYSTEMS the installers and occupants. SEE UL FIRE RESISTANCE DIRECTORY Oi p 9.5 in. x 9.5 in. (241.2mm x 241.3mm) 90G9 pad sizes available. *Minimizes noise transfer—STC-Rating of 52 when tested in STC 53 -rated wall assembly. 2. Applications 4 in. x 8 in. (101.6mm x 203mm) 3M- Fire Barrier Moldable Putty Pads MPP+ are typically used as a wall opening protective to meet building requirements, for protection of membrane penetrations made by listed steel or non-metallic electrical boxes. It is also used to seal gaps between cables in multiple penetrations (including fiber optic inner duct) and to firestop cable bundles, insulated pipe, electrical conduit and metal pipe. Larger sizedpads, 7 in. x 7 in. and 9.5 in x 9.5 in. (177.8mm x 177.8mm and 241.2mm x 241.2mm) are widely used to firestop metallic and non-metallic electrical outlet boxes up to 14 in. x 4.5 in. by 2-1/2 in. (355.6mm x 114.3mm x 63.5mm) deep. For larger applications, pads can be molded together by hand. 3. Specifications 3M- Fire Barrier Moldable Putty Pads MPP+ shall be a one component, ready -to -use, intumescent elastomer capable of expanding a minimum of 3 times at 1000°F. The material shall be thixotropic and shall be applicable to overhead, vertical and horizontal firestops. Under normal conditions, 3M`' Fire Barrier Moldable Putty Pads MPP+ shall be noncorrosive to metal and compatible with synthetic cable jackets. The putty shall be listed by independent test agencies such as UL, Intertek or FM. 3M- Fire Barrier Moldable Putty Pads MPP+ shall be tested to and pass the criteria of ASTM E 814 (UL 1479) Standard Test Method for Fire Tests of Penetration Firestop Systems and CAN/ULC S 115 Standard Method of Fire Tests of Firestop Systems. 3M`°' Fire Barrier Mo Pads MPP+ meets the requirements of the IBC, NFPA 5000, NEC (NFPA 71 and 3 N 1�"'"I Building Codes. izo a IIlIII III"111 IIDB IISB rtIP"t"fd 017'1' �m ^u°�mmuuu mV raii.ullmw u�ul um^Nw.mtn it to YII II ure IInita„luo " 5.7 rvll hm m�uµ 'nore ullormaliculonii N IImtmutoil°I lllroduop R vueWed ByAlr 11d I°°°°°I n�II Typically Specified MasterFormat (2004) Section 07 84 00 — Firestopping Related Sections Section 07 84 16 —Annular Space Protection Section 07 86 00 — Smoke Seals Section 07 87 00 — Smoke Containment Barriers Section 07 27 00 — Thermal and Moisture Protection Firestopping Section 2100 00 — Fire Suppression Section 26 00 00 — Electrical u:>atEm P (°b,l./n5/17 ME 4. Performance &Typical Physical Properties Color: Nominal Density: Nominal Thickness: Surface Burning (ASTM E 84): Heat Expansion: STC (ASTM E 90 and ASTM E 413): Tested in STC 53 rated wall assembly Dark Red 10-12 lbs./gal. (1.2-1.45kg/L) 1/10 in. (2.54mm) Flame Spread 0, Smoke Development 0 Begins at 350°F (177°C) Significant at 400°F (204°C) Free Expansion is Nominal 3 times 52 when tested on back-to-back electrical boxes VOC Less H20 and Exempt Solvents: < 250g/L 5. Packaging, Storage, Shelf Life Packaging: Corrugated cardboard box with liner between individual pads. Dimensions: 4 in. x 8 in. x l/10 in. (101.6mm x 203.2mm x 2.5mm) Unit Volume: 2.52 in.' (41.4cm3) Unit Weight: 2.7 oz (76g) Dimensions: 7 in. x 7 in. x l/10 in. (177.8mm x 177.8mm x 2.5mm) Unit Volume: 4.63 in.' (76.Ocm3) Unit Weight: 4.1 oz (116g) Dimensions: 9.5 in. x 9.5 in. x 1/10 in. (241.3mm x 241.3mm x 2.5mm) Unit Volume: 6.1 in.3 (139.8cm3) Unit Weight: 7.6 oz (215g) Storage: 3M- Fire Barrier Moldable Putty Pads MPP+ should be stored indoors in dry conditions. Shelf Life: 3M– Fire Barrier Moldable Putty Pads MPP+ shelf life is indefinite in original unopened containers. Product will not dry or crumble in opened containers. Normal stock and stock rotation practices are recommended. Consult a 3MAuthorized Fire Protection Products Distributor /Dealer or Sales Representative for 6. Installation Techniques Applicable UL, Intertek or other third party drawings and system details. Preparatory Work: The surface of the electrical box, or opening and any penetrating items should be cleaned (i.e. free of dust, grease, oil, loose materials, rust or other substances) to allow for the proper adhesion of the 3M– Fire Barrier Moldable Putty+ Pad. Ensure that the surface of the substrates are not wet and are frost -free. Installation Details: Electrical boxes must be firestopped under the following conditions: boxes larger than 16 sq. in. (103 sq. cm), if horizontal spacing between boxes is less than 24 in. (609.6mm), when multiple boxes are located in one stud cavity or if the aggregate of all boxes exceeds 100 sq. in. per 100 sq. ft. (645 sq. cm. per 9.29 sq. m) — refer to listed system details and applicable local building code requirements. For electrical box installations, a minimum of 1/10 in. (2.5mm) thick putty application is required 3M`°' Fire Barrier Moldable Putty Pads MPP+ are to be installed to completely cover the exterior of the outlet box (except for the side against the stud). To firestop penetrations, install the applicable depth of backing material (if required), remove the desired amount of putty from the pad, form (if necessary) and install as detailed within the listed system. Make sure that putty is in complete contact with the substrate and penetrating item(s). Note: Partial pads can be pieced together and the seams between partial pads should overlap a minimum of 1/8 in. with the seams worked with the fingertips to create adhesion at the seam. Limitations: Over application (i.e., using excessive amount of material) of product to vertical surfaces may cause sagging, follow system details. Product is not impaired by freezing but should be warmed to 32°F (0°C) before applying. 7. Maintenance No maintenance is expected when installed in accordance with the applicable UL, Intertek, FM or other third -party listed system. Once installed, if any section of the 3M– Fire Barrier Moldable Putty Pad MPP+ is damaged, the following procedure will apply: remove damaged putty, clean the affected area and install the proper thickness of putty, ensuring it bonds to the substrate and adjacent putty (product from damaged area can be reused if it is free from contaminants). Putty can be molded together at new/existing putty overlap. 8. Availability 3M'* Fire Barrier Moldable Putty Pads MPP+ are available from 3M Authorized Fire Protection Products Distributors and Dealers. 3M' Fire Barrier Moldable Putty Pads MPP+ are available in the following sizes: (10 pads/pack, 10 packs/case) 4 in. x 8 in. x 1/10 in. (101.6mm x 203.2mm x 2.5mm), (20 pads/case) 7 in. x 7 in. 1/10 in. (177.8mm x 177.8mm x 2.5mm), (20 pads/case) 9.5 in. x 9.5 in. 1/10 in. (241.3mm x 241.3mm x 2.5mm); red -colored firestop material. For additional technical and purchasing information regarding this and other 3M Fire Protection Products, please call: 1-800-328-1687 or visit www.3M.com/firestop. 9. Safe Handling Information Consult product's Material Safety Data Sheet (MSDS) from country -of -use prior to handling and disposal. Important Notice to User: Technical Information: The technical information, recommendations and other statements contained in this document are based upon tests or experience that 3M believes are reliable, but the accuracy or completeness of such information is not guaranteed, Product Use: Many factors beyond 3M's control and uniquely within user's knowledge and control can affect the use and performance of a 3M product in a particular application, Given the variety of factors that can affect the use and performance of a 3M product, user is solely responsible for evaluating the 3M product and determining whether it is fit for a particular purpose and suitable for user's method of application, Warranty and Limited Remedy: 3M i h 3M Fire Protection Product will be free from defects in material and manufacture for 90 days from the date of purchase from Industrial Adhesives 3M's authorized distributor. OTHER EXPRESS OR IMPLIED WARRANTIES, INCLUDING ANY IMPLIED WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. If a not coif1ilh nd exclusive remedy is, at 3M's option, replacement of the 3M product or refund of the and Tapes Division purchase price, Limitation o flit I tvvhere p i b a 4 1 able for any loss or damage arising from the 3M product, whether direct, indirect, special, 3M Center, Building 225-3S-06., mci enta or consequential, r e ��, IIS �°� DepartilTIhO�ft'�' St. Paul, MN 55144-1000 3M is a trademark of 3 ; ed under license in Canada. LEED is a trademark of U.S. Green Building Council Non -Profit Corporation. 800-328-1687 other trademarks are aIpe their respective owners. ueNww3 V � VIed Please Recycle. Printed 0c 1All iCs 'reserve t"rI w.3Mcom/frestop m A 2 eferumber98-0213-4620-4RevB R/uettByf""f"""""f"I V.)atE< P N./ >/17 3M ENGINEERING JUDGEMENT NO. 581875 MODIFIED SYSTEM NO. CLIV REQUESTED F RATING - 1 HR OBTAINABLE RATING *SEE BELOW 1. GYPSUM LID. 2. CEILING LIGHT HOUSING. 3. MPP+ MOLDABLE PUTTY PADS *DUE TO THE INCLUSION OF THE PUTTY PADS BEING INSTALLED ONTO A LIGHT FIXTURE IN THE GYPSUM MEMBRANE OF A FLOOR/CEILING ASSEMBLY, THE OBTAINABLE RATING IN THIS SCENARIO IS REDUCED TO "UP TO 1 HOUR OR AS LONG AS THE ENTIRE ASSEMBLY REMAINS INTACT IN A FIRE SCENARIO." CONFIGURATION OR ORIENTATION OF PENETRANT(S)/OPENING(S) MAY NOT MATCH SITE CONDITION(S). CONSULT CURRENT INDEPENDENT TESTING LABORATORIES (UL/INTERTEK) FOR SYSTEMS OR DESIGN DETAILS PROJECT: THE FORUM EV: DATE: I DESCRIPTION D 0 03-23-17 ORIGINAL ISSUE - I�� y�y II��� USE AS ' �u ui ui ul II� ,. TION D CUMENT. FREWEMED,FDR IrlMlN 3M Fire Protection Mme■ C silo VAIING NOT TO SCALE. SIGNATURE: D DWG. LOCATION: DATE: 581875.DWG 03-23-17 ALL STATEMENTS, TECHNICAL INFORMATION AND RECOMMENDATIONS CONTAINED HEREIN ARE BASED ON TESTS WE BELIEVE TO BE RELIABLE, HOWEVER, SINCE THE CONDITIONS OF USE AND APPLICATION ARE BEYOND OUR CONTROL, 3M SHALL NOT BE LIABLE FOR ANY DAMAGE, DIRECT OR CONSEQUENTIAL, RESULTING FROM THE USE OF THIS MATERIAL OR DESIGN. 3M'S ONLY WARRANTY SHALL BE TO REPLACE ANY OF OUR PRODUCTS PROVED TO BE DEFECTIVE. ENGINEERING JUDGMENT FOR: 3/23/2017 Jill Manetas 3M FPP Sales Northern California EI Cerrito, CA 94530 Project: The Forum Contractor: Bay Area Enterprises Fire Stopping Category: CLIV Hourly Rating Requested/ Type: 1 Hour / F Housing Type: Metallic Housing Dimensions: Max. 5 in. Diameter, 7 inch Tall Special Conditions: 5 in. round and 7 in. tall ceiling light housing making a membrane penetration through the gypsum lid only of a 1 hour rated floor/ceiling assembly. 1 hour rating required via CLIV. Application Details: To firestop this application, install in accordance with UL System R9700.CLIV with the following modifications/clarifications: 1. Due to the inclusion of the putty pads being installed onto a light fixture in the gypsum membrane of a floor/ceiling assembly, the obtainable rating in this scenario is reduced to "Up to 1 hour or as long as the entire assembly remains intact in a fire scenario." Note: The seams between partial pads or full pads being joined together should overlap a minimum of 1/8 in. and the seams worked with the fingertips to create adhesion at the seam. Note: Heat transfer along the penetrating item into the interstitial space may affect the floor/ceiling assembly's structure, influencing the degree the assembly deflects. The project design team is advised to consult with the manufacturer of the particular floor -ceiling design to confirm acceptability. Note: Because of the possible heat capture within the light fixture due to it being wrapped with the MPP+ Moldable Putty, the installation of the MPP+ Moldable Putty onto the light fixture must be approved by the light fixture manufacturer to ensure that there is not a violation of the light fixture warranty. 3M Fire Barrier Material: MPP+ Moldable Putty Pads Based On: CLIV Additional Referenced System(s): (See Attached Drawing) This Engineering Judgment (EJ) is based upon the sole and exclusive use of 3M brand Fire Protection Products as described within. Modification of any of the parameters of this EJ, including, without limitation, the use of non -3M brand Fire Protection Products, shall render this EJ null and void. The firestop design is expected to achieve the hourly rating indicated above. This engineering judgment is based on performance results obtained in testing with independent laboratories and / or internal 3M fire tests, which have been tested in accordance to ASTM E 119 (UL 263). Engineering Judgment Prepared By: Reviewed By: Kevin Rennek:e 581875 Te-chnical Service Representative cc: Jill Manetas Email: jrmanetas@comcast.net 3M Industrial Adhesive and Tapes Fire Protection Products 3M Center, Building 230 -B -S-37-03 St. Paul, MN 55144-1000 p EWA .: l..D I::CU CFI°-COWI[]ANCE Revawed a yAlrndd I°°°°°.ons iI u)atE„: n4/n5/1 7 Page 1 of 1 TESTING ENGINEERS, INC. 2811 Teagarden St. 510-835-3142 510-834-3777 fax San Leandro, CA 94577 800-660-3142 PROJECT # 64915 PROJECT: 23500 Cristo Rey Drive, # 405E (Peters) DATE HOURS Permit # B-2017-0172 6/2/17 INSPECTOR J. Foster San Leandro • San Jose • Martinez INSPECTION REPORT Week Ending: 6/2/17 TYPE OF INSPECTION: Epoxied Anchors PLACE OF INS Jobsite Reported to Tony Luis of Bay Area Enterprise at the jobsite as requested. Witnessed the drilling of holes of proper diameter and depth. Observed the cleaning of holes and the injection of Simpson Set XP epoxy (exp. 5/18). Witnessed the proper insertion of seven (7) 5/s" diameter Allthread anchors, 12" in length, embedded 6" at unit 403E and 405E dividing wall, fixing wood floor plate to concrete slab. The preceding work was, to the best of my knowledge, in compliance with approved plans and specifications, including revisions by engineer and Drawing S.1, Detail 1, dated 4/6/17. Reviewed by : 33 vid Chippero Special Inspection Division Manager 1cc: Bay Area Enterprise / G. Feist MHA Consulting Engineers / M. Huang, PE CE City of Cupertino / Bldg. Inspection Dept. RECE11T� JUL 0 3 2011 B -Y 2 The results presented in this report relate only to the item(s) tested/inspected and can be reproduced only in its entirety unless written permission from TEI is obtained. Page 1 of 1