B-2016-2821CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-2821
19638 STEVENS CREEK BLVD CUPERTINO, CA 95014-2465 (369 06 012)
OWNER BUILDER
OWNER'S NAME: EVERSHINE VI, LP
DATE ISSUED: 04/17/2017
OWNER'S PHONE: 408-343-1088
PHONE NO:
LICENSED CONrRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER BUILDER Date
X BLDG _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:
T.I. - TRASH ENCLOSURE (288 S.F.) - MARKET PLACE
I hereby affirm under penaltyof perjury one of the following two declarations:
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.
'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.
Sq. Ft Floor Area:
Valuation: $30000.00
APPLICANT CERTIFICATION
I 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 06 012
A (Tenant Improvements),A (Tenant Improvements),A
representatives of this city to enter upon the above mentioned property for
(Tenant hnprovements),A (Tenant Improvements),A
inspection purposes. (We) agree to save indemnify and keep harmless the
(Tenant Improvements),A (Tenant Improvements),A
City of Cupertino against liabilities, judgments, costs, and expenses which
(Tenant Improvements),A (Tenant Improvements),A
may accrue against said City in consequence of the granting of this permit.
(Tenant Improvements),A (Tenant Improvements),A
Additionally, the applicant understands and will comply with all non -point
(Tenant Improvements)
source regulations per the Cupertino Municipal Code, Section 9.18.
PERMIT EXPIRES IF WORK IS NOT STARTED
Signature Date 4/17/2017
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
OWNER -BUILDER DECLARATION
180 DAYS FROM LAST CALLED INSPECTION.
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
Issued by: AbhyAvende
1. I, as owner of the property, or my employees with wages as their sole
Date: 04/17/2017
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
RE
2 I, as owner of the property, am exclusively contracting with licensed
-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
contractors to construct the project (Sec.7044, Business & Professions Code).
{ `
installed without first obtaining an inspection, I agree to remove all new materials for
I hereby affirm under penalty of perjury one of the following three declarations:
inspection.
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
Signature of Applicant:
performance of the work for which this permit is issued.
Date: 4/17/2017
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
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
permit is issued.
I certify that in the performance of the work for which this permit is issued, I
HAZARDOUS MATERIALS DISCLOSURE
shall not employ any person in any manner so as to become subject to the
I have read the hazardous materials requirements under Chapter 6.95 of the
Worker's Compensation laws of California. If, after making this certificate of
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
exemption, I become subject to the Worker's Compensation provisions of the
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Labor Code, I must forthwith comply with such provisions or this permit shall
Health & Safety Code, Section 25532(a) should I store or handle hazardous
be deemed revoked,
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
APPLICANT CERTIFICATION
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I certify that I have read this application and state that the above information is
the Health & Safety Code, Sections 2505, 25533, and 25534.
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
Owner or authorized agent: /
—c t
to save indemnify and keep harmless the City of Cupertino against liabilities,
Date: 4/17/2017
judgments, costs, and expenses which may accrue against said City in
CONSTRUCTION LENDING AGENCY
consequence of the granting of this permit. Additionally, the applicant understands
I hereby affirm that there is a construction lending agency for the performance
and will comply with all non -point source regulations per the Cupertino Municipal
of work's for which this permit is issued (Sec. 3097, Civ C.)
Code, Section 9.18.
Lender's Name
Lender's Address
Signature Date 4/17/2017
d
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Mh- TRASH
- - - CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
1000 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUkRTIi` 0 (408) 777-3228 - FAX (408) 777-3333 • bulldin a%cupertino.orq
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PPE•APPLICATION V IFY P IDE Y F '::::::.., ::::i::. ..-._ -
�� ES E5, ROY COP O PLANNER SNAME: .....:::::. .:-v: •:::;:::;,:::.:.._.:
:=i2ECEfVEDBY:':7`::�'r;=;'.='�=_'L? -,�,-�:_TQ7?;L'Y �UATFON:`;�.L`='._::.'
PLANNING APPLi! � NO PLANNaiG APPROVAL LETTER -� .._
By my signature below, I cerlify to each of the following: I ani the properly owner or authorized agentto act on th propeky owner's behalf. I have read this
application and the information I have providedis 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 rela =W744-
uctlon. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicantlAgent: Date: "�a '[lam
SUPPLEMENTAL INFORMATION REQUIRED r iiu ciItci Tr.
New SFI) or Multifamily dwellings: Apply for dernotition permit fnr []? 'OVER i cciYiiv? e
existing building(s). Demolition permit is required prior to issuance of buildinb
permit for new building.
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if any hazardous Materials are being used as part of this project. .L:iiic$> w
_ Copy of Planning Approval Letter or Meeting with Planning prior to
submittal ofBuilding Pennitapplication.
Bfdg,1p1� 2011.doc revised 03116111
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building2cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS
STEvewS C`"< 5s v4D
APN3 6 `� = O G • O ('4
OWNER NAME
OWNER ADDRESS
DESCRIPTION OF WORK: CON 9TILV CT ( K) C: t-JOrk' ovtk 4) TAA!&
5NC-LQSe R -e
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
'.hj n. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
802er" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
in urance coverage for injuries to workers on my property.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
th construction and are not hiring a licensed Contractor to assume this responsibility.
43. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
ptect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
�5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
fe eral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
4me to serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
re idential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is erformed under contract with a licensed general building Contractor.
8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwneBuildesForrn 2010.doc revised 04114110
e
° . I understand I may obtain more information regarding my obligations as an "employer" from the Internal
Reve � ue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
�10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
( 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
U� 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: P,k / A Lender Address: N
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification accerble to the city may be required to be presented when the permit is issued
to verifythe property owner's si natur .` /
Property Owner's Signature: Date: A
1
--------------------------------------------------------------------------------------------------------------------------------------------
(NOTE. The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature:
Date:
OwnerBuilderForm 2010.doc revised 04114110
2001 Crow Canyon Road,Suite 100
San Ramon,CA 94583-5387
CONSOLIDATED ENGINEERING Tel.925 314-7100 Fax.925 855-7140
L• A a.6:. ,.0: ,1111 .A' „T. -0. R 'I; E S www.ce-labs.coni
INSPECTION/TESTING REPORT
Date Of Issue: 9/26/2017
RE: Marketplace Building A Trash Enclosure Canopy
Rpt City of Cupertino Fegni
To: 10300 Torre Avenue
Permit B2016-2821
Cupertino,CA 95014 /v 3_ 17 Cm. "1033665
Attn:Building Department
Inspection Date(s): 9/15/2017
Location: Jobsite
Report# 170915Field
Inspector(s): Justin',Koenig,Paul Cottingham
PROOFLOAD/FIELD WELDING
On the above date,our representatives inspected the referenced project.
Please refer to the attached reports for details and locations of our testing and/or inspection services for the above noted date.
Work inspected/tested was in compliance with approved plans and specifications.
CC: Enclosures (5) Reviewing Engineer: Dan Allopenna,PE
Evershine VI(ER) Evershine VI(ER)
Alvernaz Construction(ER) TIACIF r
ecCity of Cupertino(P) �{_
Peoples Associates Structural Engineering(ER) i
087442
cram
°P CA10
All reports are submitted as the confidential property of our clients.Publications of statements,conclusions,or extracts is revised pending written approval.
Form ID 017 Rev.0
C.ONSOLIDATED`ENGINEEFt11VG Structural Steel Welding
Project Name (Marketplace Building A Trash Enclosure Canopy ) DSA File# ( )
CEL Project# @033665 ) DSA Appl# (
Project Location (19638 Stevens Creek Boulevard,Cupertino,CA 95014 ) LEA# ( )
Contractor (AIvernaz Construction ) OSHPD# ( )
Date (09/15/2017 3 Day (Friday 3 IR# (_ 3 Permit/Appl# 02016-2821 )
Drawing No. (S1,S2 3 Detail No. *,B 3 Other ( )
Work at: ❑ Shop l Jobsite Type of work: ► Structural Steel
For shop inspections:
Shop Name: ( ) Reported to(Name):(Jerry Rodriguez )
Address: L 3 Company:�4lvernaz Construction )
❑ Collected 0 Checked mill certificates, Sampled: ( )
Verified: N Welder,qualifcation N Procedure qualification N .Weld procedure specification
o
Visually inspected the: ❑• In progress Qualified Welders: (Gerardo Rodriguez Jr,3453,Jerry Rodriguez,3446 )
O ,
r N Completed Using Electrodes: (NR-211-14P )
c
/
'a SMAW 0 Filler Metal Type(s)E ( ) SAW 111 Filler Metal Type(s)E,( )
co
FLAW Filler Metal Type(s)E (71T-11 ) GMAW 0 Filler Metal Type(s)E ( )
co
2 Other ❑ Fillet Metal Type(s)E ( ) ❑ Verified proper electrode storage. ;
Preheat temperature maintained N at (32 ) C ' Maintained per WPS requirements ,
Maintained per AWS D1.1
d
m Verification of
E
N Wire Speed , Arc Voltage e Current,and Deposit N Proper Fit Up
a Rate per WPS
❑ Groove welds ❑ Complete penetration• ❑ Partial penetration ® Flare-bevel
p Fillet welds: _4 single-pass multi-pass'; ❑ Direct ❑ Indirect butt splice on reinforcing steel
w
4; 0 Other ( ) ;
W
c For: e Base plate 111Gusset plate ►-I Connection plate ❑ Moment plate ❑ Plate-to-plate Splices
0
✓ ❑ Stiffener plate ❑ Reinforcing steel '❑ Brackets N Bent plate ❑- Beam to column Connections
c ❑ Other: ( )
co
E▪ at: ❑ Wide flange columns: ❑ Wide flange beams N Tube steel columns , N Tube steel beams ❑. Embeds
o
❑ Beam to column ❑ Girder to column ❑ Column to column splice ❑ Chord bar splices ,
❑ Diagonal brace to ( , .) ❑ Angle to ( )
CIStuds to( ) 0 Other ( )
o
ID In Inspected on metal decking
N Arc spot welds ►:! Stitch welds ❑ Shear studs 0 Button punch
2
Form ID 017 Rev.0
CONSOLIDATED ENGINEERING
;Et 0 R ,A ;T, 0 R., It S Structural ee Welding
Refer to the attached: 1:81 Field Inspection Record El Member Completion Record 0 Material Identification Record
Work inspected was: Egi Completed 0 In progress 0 Pending approval Li W.I.P.punch list
E• 0 Non-compliance report was left with contractor
co 0 Items were reinspected and 0 Accepted 0 Remain in progress
O• See the attached 0 Punch list Li Non-compliance Item#
o.
& Issues/Problems? (0Yes oN0)
Notified: ( ) Company Name:
•
Trash Enclosure Canopy
West of Bldg A
Tube Steel Beams&Columns,Base Plates,Metal Decking
E
E
0
cu
•
This Work Was ) INSPECTED IN ACCORDANCE WITH THE REQUIREMENTS OF THE OITY ) APPROVED DOCUMENTS
The Work Inspected Met THE REQUIREMENTS OF THE (CITY ) APPROVED DOCUMENTS
Material Sampling ttl/A PERFORMED IN ACCORDANCE WITH THE OITY ) APPROVED DOCUMENTS
Signature of Special Inspector Cc71/21—
Date (9/15/2017 )
Print Name/Title Cottingham
Certification#: (8146019
Form ID 020 Rev.O
COAISOL-IDATED ENGINEERING
Field Inspection Record=
Project Name Marketplace Building A Trash Enclosure Canopy - ) - - .: -, - - =_ --DSA File# ( --—' - - )
CEL Project# (1033665 - DSA Appl#- - - - -
Project Location (19638 Stevens Creek Boulevard,Cupertino,CA 95014 - ) - -LEA# -( - -- J
Contractor (Alvernaz Construction - ) OSHPD# ( )
Date (09/15/2017 ) , Day (Friday 1 IR.# (. ) Permit/Appl# (B2016-2821 9
Weld/Connection Type Member/Joint T pe N.D.E.
® Field Inspection o ate P n t ati n Gro Weld HSB nh strep th SC Bolt ate o olumn _ uJei1stoei yetrgg �Note:Usese cratelinefor each rejected weld. ggp 1 c Upon reinspection,tF weld is rejected,list weld as a . s sjeel��od � camib beam mm a Deck preC pprr �m iiI�o .21
MSF/D Meta tub raming7�Dryooll ,grqu s ng
new rejected weld. - - - _
Weld/ Member! NDE Accept/ Re aired! --Level __ - Locations - - _ - Visual
Status Remarks Type Joint Type - --- -- -Type.--- -Reject- Reinspected
- - - -
1st FB,FW,AS,S TS,DB,PB Trash Enclosure.Canopy Framing,West of Bldg Yes N/A N/A- Accept - - Comp_---_Tube Steel Beams&Columns,_Plates& _ _.
Metal Decking
Notes/
Comments:
This Work Was 9 INSPECTED IN ACCORDANCE WITH THE REQUIREMENTS-OF THE (CITY-. 9 APPROVED DOCUMENTS
The Work Inspected Met - 9 - - THE REQUIREMENTS OF THE (CITY - .) APPROVED DOCUMENTS
Signature of Special Inspector .1 LI_ Date (9/15/2017 9 '
Print Name/Title (Paul Cottingham 9
- - - Certification#: (8146019 -
9
Form ID 011 Rev.0
p
GONSOLIDATEDENGINEERING Pry®fl01C1 Testing
L .A ®' J.0.-:li.- -A'"T O '.Rr i1, ,.8 .;S
• Project Name (Marketplace Building A Trash Enclosure Canopy • 9 DSA File# ( -
CEL'Project# (1033665 9 •DSA Appl# ( 9
Project Location (19638 Stevens Creek Boulevard,Cupertino,CA 95014 9 LEA#
. Contractor ( 9 OSHPD# (
Date (09/15/2017 ) Day (Friday. 9 IR# ( ) Permit/Appl# (B2016-2821 9
Reported to: (Jerry rodriguez •
9
Performed.proofload tests on: (5/8"all thread •
Installed at: (Trash enclosure canopy footing •
® See the attached data sheet(s)for location and quantity of anchors/dowels and the specified applied loads and results.
'(100.00 )'%•of the total installed were tested. Total Installed: (12 9 Quantity Tested: (12 . )'
0 Loads were applied.in direct tension by using a calibrated hydraulic ram
•
Ram size/No. ( ) Gauge No. ( ) Calibrated(date) (
Each anchor/dowel tested was individually proofload tested to the specified load of ( )pounds.
® Loads were applied by use of a torque wrench.
•
"All anchors/dowels tested were found to be satisfactory with no visible evidence of distress or failure.
0 ;except as noted •
Each anchor/dowel tested'was individually checked for proper installation by applying a specified torque of(60 ft.lbs:
Notes/' i
'Comments: '
•
•
•
This Work OVas 9 INSPECTED IN ACCORDANCE WITH THE REQUIREMENTS OF THE•(CITY 9 APPROVED DOCUMENTS
The Work Inspected (et 9 THE REQUIREMENTS OF THE (ITY .9 APPROVED DOCUMENTS
Material Sampling (U Vas 9 PERFORMED IN ACCORDANCE WITH THE (CITY 3 APPROVED DOCUMENTS
Signature of Special Inspector ] Date (9/17/2017 9
Print Name/Title (Justin Koenig
Certification#: ( •
;` +
Form ID 012 Rev.1
_
CONSOLIDATED-ENGINEERING _
T -at R , .E- , roofload Testing Sum
'Cmary _
Project Name (Marketplace Building A Trash Enclosure Canopy )- - DSA File# ( - - )
CEL Project# (1033665 = ) -- -- •DSA Appl# (- -
Project Location (19638 Stevens Creek Boulevard,Cupertino,CA 95014 ) - - _ =__ _ LEA# '(
Contractor ( )—` OSHPD# ( )
Date (09/15/2017 ) - Day (Friday ) IR# ( ) Permit/Appl# (82016-2821 )
Load Test Performed on Q Rebar ❑❑ Shotpin/Wire Assembly -0 Anchors Installed in Concrete❑® Installed in Masonry Q❑
Method:Anchors were proof loaded to the specified load using the following apparatus:
❑❑ Dynamometer ❑® Torque Wrench ❑❑ Hydraulic Jack System ❑❑ Scale ❑❑ Other: ( )
Quantity Tested . Quantity Retested Applied Load
Dowel/Anchor. Total Total lbs.tension or
Test# Test Location Type/Size _Installed. Tested. - Pass . Fail Pass - . Fail ft.-lbs.torque
1 Trash enclosure canopy footing - 5/8" - 12 - 12 12 - 0 60
Remarks:
The Work.Inspected Was 9 SAMPLED AND TESTED IN ACCORDANCE WITH THE REQUIREMENTS OF THE CITY 9 APPROVED DOCUMENTS .
The Material Tested Met 9 THE REQUIREMENTS OF THE (CITY ) APPROVED DOCUMENTS
liSignature of Special Inspector 9 Date (9/17/2017 )
- Print Name/Title (Justin Koenig 9
Certification#: ( 3