B-2017-0559CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
20400 STEVENS CREEK BLVD STE 370 CUPERTINO, CA 95014-2298 (369 01 028)
CONTRACTOR:
KOSTTCH
PERMIT NO: B-2017-0559
ENTERPRISES INC
FREMONT, CA 94538
OWNER'S NAME: CUPERTINO CITY CENTER BUILDINGS
DATE ISSUED: 04/11/2017
OWNER'S PHONE: 408-873-0121
PHONE NO: (510) 657-4460
LENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class CA Lic. #461005
Contractor KOSITCH ENTERPRISES INCDate 08/31/2018
X_ BLDG X ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
— MECH — RESIDENTIAL X COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations:
CUPERTINO CITY CENTER - SUITE 370; - 3RD FLOOR; T.I. -
INSTALL (8) NEW CIRCUITS AND CONNECTIONS
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
= performance of the work for which this permit is issued.
2:- I have and will maintain Worker's Compensation Insurance, as provided for by
s Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Sq. Ft Floor Area:
Valuation: $10000.00
APPLICANT CERIMCATION
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 01 028
A (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 this permit.
Additionally, the applicant understands and will comply with all ll non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature/� S Date 4111/2017
Issued by: AbbyAyende
OWNER -BUILDER DECLARATION
Date: 04/11/2017
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 roofing material being installed. If a roof is
1. I, as owner of the property, or my employees with wages as the{ 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: 4/11/2017
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
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
Worker's Compensation laws of California. If, after making this certificate of
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
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. ,
Owner or authorized agent: Z� X_r� L,"Z�
—1
APPLICANT CERTIFICATION
Date: 4/11/2017
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.
1 understand my plans shall be used as public records.
Signature Date 4/11/2017
Licensed
Professional
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CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - buildinaC&cupertin0 Or®
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DESCRIPTION OF WORK°-
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❑ ATTACH
# DWELLING UNITS:
IS A SECOND UM1TT YES
SECOND STORY ❑YES
BEINGADDED? []NO
ADDITION? ONO
PRE•APPLICATION ❑YES ff YES, PROVIDE COPY OF
PLANNINGAPPL# []NO PLANNING APPROVAL LETTER
IS THE BLDG AN ® YES
EICHLERROME? NO
RECEIVED BY:
OTAL VALUATION:
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By my signature below, I certify to each of the following: I am the property owner or authorized agent tb act on the property owner'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 laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: ssg= 42,,,—� Date:
SUPPLEMENTAL M70RMATION REQUIRED
PIAN CHECK TYPE
ROUTING SLIP
❑ ovER -THe.cOlmrTeR
❑ BLIII DING PI npraEvrEw
_ 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.
❑ EXPRESS - ,_
❑- PLANNING PLAN REVIEW ' - -
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD_
❑. PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ ` FIltE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
El MAJOR
❑ SANITARY SEWER DISTRICT
0 ENVIRONMENTAL HEALTH
WANE
BldgApp 2011.doc revised 06121111