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14120113CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10500 N DE ANZA BLVD CONTRACTOR: DEVCON PERMIT NO: 14120113 CONSTRUCTION INC OWNER'S NAME: MISSION WEST PROPERTIES LP IV 690 GIBRALTAR DR DATE ISSUED: 12/22/2014 OWNER'S PHONE: 4087834444 MILPITAS, CA 95035 PHONE NO: (408)942-8200 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL ❑ APPLE -1ST FLOOR ADDITION OF GLASS PARTITIONS License Class 6A C17C. Lic. # C� (p AND &.,,4 Z y �S SLIDING GLASS DOORS W/ (E) MINOR STRUCTURAL Contractor - Date 1 hereby affirm that I am licensed under the provisions of Chapter 9 deferred #1- restroom plans- issd ote 2/4/2015 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declaration 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 Ft Floor Area: Valuation: $198500 performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provi y Section 3700 of the Labor Code, for the performance of the work ich th APN Number: 31622017.00 Occupancy Type: permit is issued. A� APPLICANT CERTIFICATIOPY� ppw� I certify that I have read this application and state that the atV nformation is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 D PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAY M LA CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the L4 granting of this permit. Additionally, the applicant understands and will comply Issued by: Date with all non -point source gulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signatur ate 2 All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(x) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and 25533, 5534. 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 the Health & Safety Code, Sections 051 y t5 permit is issued. Owner or authorized agent: t� Date: 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO FRO FEE ESTIMATOR — BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt otc )_ Thoco foot aro hacod nn tho nroliminary infarmatian availahlo and aro nnh? an ocfimnto_ Cnnfart the Dont far addn'l info_ FEE ITEMS (Fee Resolution 11-053 M.'7111113) ADDRESS: 10500 n de anza blvd DATE: 02/04/2015 REVIEWED BY: Mendez APN: BP#: "VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: 0.0 PENTAMATION PERMIT TYPE: WORK deferred #1- restroomplans- issd otc 2/4/2015 SCOPE NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt otc )_ Thoco foot aro hacod nn tho nroliminary infarmatian availahlo and aro nnh? an ocfimnto_ Cnnfart the Dont far addn'l info_ FEE ITEMS (Fee Resolution 11-053 M.'7111113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (F)Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? ()Yes Q No $0.00 Suppl. Insp. Fee -0 Reg. ® OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 E) Work Without Permit? 0 Yes (F) No $0.00 Advanced Planning Fee: $0.00 Select allon-Residential Building or Structure 0 Strong Motion Fee: $0.00 1.0 hrs $143.00 Inspections isT1NsP Inspection, Hourly Bldg Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $143.00 TOTAL FEE: 1 $143.00 Revised: 01/06/2015 CUPERTINO DEFERRED # CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDINAM06L 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(dcupertino.orcl ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/ TI Q REVISION /DEFERRED ORIGINAL PERMIT # 14120113 PROJECT ADDRESS 10500 N. De Anza Blvd APN# OWNER NAME Apple, Inc. / Mission West Properties PH0NE408-783-4444 E-MAIL anh vu@apple.com STREET ADDRESS 1 Infinite Loop CITY, STATE, ZIP Cupertino, CA FAX CONTACT NAME Kevin Irwin PHONE408-712-9856 E-MAIL kirwin@devcon-const.com STREETADDREss690 Gibraltar Dr. CITY, STATE, ZIP Milpitas, CA 95035 FAx408-262-2342 ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT 9 CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME Kevin Irwin LICENSE NUMBER 399163 LICENSE TYPE CA GC 1 BUS. LIC # 11068 COMPANY NAME Devcon Construction, Inc. EMAILkirwin@devcon-const.com FAx408-262-2342 STREETADDREss690 Gibraltar Dr. CITY, STATE, ZIP Milpitas, CA 95035 PHONE408-942-8200 ARCHEEITECT/ENGINER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK Deferred submittal #1 - restroom plans for reference. EXISTING USE B/A3 PROPOSED USE CONSTR. B/A3 I -B TYPE # STORIES 4 USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG AREA NEW FLOOR AREA DEMO AREA TOTAL NET AREA B/A3 N/A BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH I ❑ ATTACH I # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? []NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVED BY: TOTAL VALUATION: PLANNING ADPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? NO ❑ NIA By my signature below, I certify to each of the following: I am the property owner or authorized agen o act 3-ffie owner's behalf. I have read this application and the information I have provided is co ect. I have read tb rlption of Work and v , ify it i gree to comply with all applicable local ordinances and state laws relating to buil ruction. I e representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: 2 l S —r SUPPLEMENTAL INFORMATION REQUIRED CHECK TYPE RO LIP New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building OVER-THE-COUNTER BUILDING PLAN REVIEW 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 ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10500 N DE ANZA BLVD CONTRACTOR: DEVCON PERMIT NO: 14120113 CONSTRUCTION INC OWNER'S NAME: MISSION WEST PROPERTIES LP 1V 690 GIBRALTAR DR DATE ISSUED: 12/22/2014 OWNER'S PHONE: 4087834444 MILPITAS, CA 95035 PHONE NO: (408)942-8200 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIALE] APPLE- IST FLOOR ADDITION OF GLASS PARTITIONS License Class (.1 0 C Lia # 3�/� b AND Dt� C i Z Z'2 SLIDING GLASS DOORS W/ (E) MINOR STRUCTURAL Contractor v cj Date / 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 I hereby affirm under penalty of perjury one of the following two declarations: 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 Sq. Ft Floor Area: Valuation: $198500 performance of the work for which this permit is issued. 1 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 APN Number: 31622017.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FR A T CALLED INSPECTION. 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 Issued by: Date: with all non -point re gulations per the -C rtino Municipal Code, Section 9.18. "`' 12 2. 1� to (.9 RE -ROOFS: Signature / w~""` ""' Date.,„_. 1 All roofs shall be inspected prior to any roofing material being installed. Ifo roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Workers material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and 1 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 the Health & Safety Code, Sections 2505, 2553a.OTM 25534. f 2.2.2. i Owner or authorized agent: IV Date, permit is issued. 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with al l non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CONSTRUCTION PERMIT APPLICATION 13 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION n� 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 a� V CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • build ingcDcupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ® ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 10500 N. DeAnza Blvd API #316-22-017 OWNER NAME Apple Inc PHONE 408-738-4444 E-MAIL STREETADDRESS 1 Infinite Loop CITY, STATE, ZIP Cupertino CA 95032 FAX CONTACT NAME Terry Fullerton PHONE 408-519-8383 7E -MAIL tfullerton@devcon-const.com STREET ADDRESS 690 Gibraltar Drive CITY, STATE, ZIP Milpitas, CA, 95035 FAX 408-946-5513 ry� ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT 1q CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME DEVCON Construction LICENSE NUMBER 399163 LICENSE TYPE B BUS LIC # COMPANYNAMEDEVCONConstruction E-MAIL tfullerton@devcon-const.com FAX408-946-7713 STREET ADDRESS 690 Gibraltar Drive CITY, STATE, ZIP Milpitas, CA 95035 PHONE408-519-8372 ARCHITECT/ENGINEERNAME Brent Downing LICENSE NUMBER C-32444 BUS. LIC# COMPANY NAME DEVCON Construction E-MAIL bdown in devcon-const.com FAX 408-942-7713 STREET ADDRESS 690 Gibraltar Drive CITY, STATE, ZIP Milpitas, CA, 95035 PHONE408-942-8200 DESCRIPTION OF WORK Addition of Glass partitions and sliding doors, with Electrical, Structural and minor Wall demo. EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES B B la 4 USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG AREA300 NEW FLOOR AREA DEMO AREA TOTAL NET AREA Office B 300 198,500.00 BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPOqARRFAGARAGE AREA: DETACH ❑ATTACH I I I I # DWELLINGUN- rrS IS A SECOND UNIT COND STORY ❑ YES - BEING ADDED? DITION? ONO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVED -BY: - TOTA VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO j 5 C6 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 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 but 111'istruction. orize representatives of Cupertino to enter the above -identified pro erty for inspection purposes. Signature of Applicant/Agent Date: 1�- 2�� SUPPLEMENTAL tFORMATION REQUIRED PLS TYPE" ItOUTING gilP'_ 0 OVER-T8E$ COUNTER � , ❑ 'BIS DING PLAN REVIEW 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 ❑--STANOARD ❑ ,1`UBLIcWOR1G form if any Hazardous Materials are being used as part of this project. ❑ LARGE 0 FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR 13 SANiI1ARY ;EWERDiSTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp 2011.doc revised 06/21111 CITY OF CUPERTINO FM -7 FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10500 n de anza blvd TYPE OF CONSTR. DATE: 12/22/2014 REVIEWED BY: Mendez BP FEES APN: BP#: II-B,III-B,IV,V-B 300 `VALUATION: 1$198,500 •PERMIT TYPE: Building Permit $588.00 PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: $0.00 PME Plan Check: PENTAMATION 1 B TI PERMIT TYPE: WORK apple- 1 st floor addition of glass partitions and sliding lass doors w/ a minor structural SCOPE Permit Fee: $588.00 Suppl. Insp. Fee:Q Reg. OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,III-B,IV,V-B 300 $2,097.00 IBTIPLNCK $588.00 IB7 INSP hrs $0.00 PME Plan Check: $0.00 Permit Fee: $588.00 Suppl. Insp. Fee:Q Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 TOTALS: 300 $2,097.00 $0.00 $588.00 MECH, HOURLY 0 Yes E) No PLUMB, HOURLY Q Yes Q No ELEC, HOURLY Q Yes Q No NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fce Resolulion 11-053 E f 7, V13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,097.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Q Reg. 0 OT F0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $588.00 Suppl. Insp. Fee:Q Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 F -T 0 G Work Without Permit? Q Yes (F) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 Strong Motion Fee: IBSEISMICO $55.58 Select an Administrative Item Bldg Std,., Commission Fee: 1BCBSC$8.00 SUBTOTALS: $2,748.58 $0.00 TOTAL FEE: $2,748.58 Revised: 10101/2014 STATEMENT OF SPECIAL INSPECTIONS, 2013 CBC COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 950143255 (408) 777-3228 • FAX (406) 777-3333 - building cuoertino oro SITE 10500 N. DeAnza Blvd ADDRESS APN 316-22-017 BP# Mission West .. Owner............................................................................................................ Contractor.P..�Yt?Ar?.G,RnSkC4.4144................................... Address... 10050 Bandley Dr. _...................... Address..690 Gibraltar Dr ................................................................................... City/St...Cupertino CA...................... Zip..96014 Phone408.725:0700 Ciry1St..Milpitas CA Zip 95035 Phone 09:912:990 Devcon Construction Applicant......................_.............................................................................. SEI Eng! neers Inc . EngineerlArchitect.................... 690 Gibraltar Drive Address........................................................................................................... 4970 EI Camino Real Address..................... Mil itas CA 95035 408-942-e200 City/St.............P.............................Zip...........................Phone..................... Los Altos CA 94022 Cit 1St..........................................2i Phone 650-938-2200 PROJECT DESCRIPTION:t„`A J �� w ( � ,�� This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This form is structured after and used by p ission from the Structural Engineer Association of Northern California's (SEAONC) mode statement of Special Inspections. ded with this form is the following: ❑ -LIST OF SPECIAL IN GENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the ons for this project ❑ 'SCHEDULE OF SPECIAL NS T " page 3 -- 6). The Schedule of Special Inspections summarizes the Special Inspections and tests required.' Sp n ctors will refer to the approved plans and specifications for detailed special inspection requirements. Any a at to inspections required by the approved plans and specifications shall also be performed. Special Inspections and Tesfi�rj�G }}��jj��r01 acro n the approved plans and specifications, this statement and CBC Sections 17 , 1705, 1706, 1'k07y%lna�0 f lipf{�I*po a ed to the Building Official and the Registered Design P Responsible,Et6di� ��'anc''e with CBC 2. A I0-4 Pf Special intidocumenting required Special Ins ons, testing and correction of any discrepancies noted in th shaN ubrnitled, f to issuance of a Certificate of U e and Occupancy (Section 1704.1.2). The Final Report will do ' CS equired special. irA�g E�y5y�,.,COMpL 1'1kT4 ptgt V LiL� i#JcpanG�es�ngi inspections. The Owner r.�ogi�ek is-tsr"her Zsbligabon to ensure that the construction complies with the approved permit documents and to implement this program of special inspections. In partial fulfillment of these obligations, the Owner will retain and directly pay for the Special Inspections as required in CBC Section 1704.1. This plan has been developed with the understanding that the Building Official will: • Review and approve the qualifications of the Special Inspectors who will perform the inspections. • Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their duties as called for in this Statement of Special Inspection. Review submitted inspection reports. Perform inspections as required by the local builping code. 1 have read Prepared By: Project Pi Engineer ❑ Architect Registered Design Professional In Charoe Owner Name: Owners Authorization InspectionAgency/ Inspector Name: `j'`G Tt Util � W Building Official or esignee: of this statement LIC.# . . Lic.# ...... Date: ......... Date:12/16/2014.....JJ......JJ.............. ......... Date:Z.t?..� b/�d SpeciainspectionForm 2012.doc revised 091002 LIST OF SPECIAL INSPECTION AGENCIES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special Inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre -approved and listed on Cupertino's approved Special Inspector's list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Inspection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order" and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow two weeks to complete the application process. The following are the testing and special inspection agencies that will be retained to conduct tests and inspection on this project: EXPERTISE FIRM i INSPECTOR INFORMATION 1. Special Inspection (except for FirmN..CM-..Addr.... ...U1Ym......... 1. ..Mn'.!'...:rE............. geotechnical) .. ..... state ........�`... Zip ....1. yam... City.........� ......... 1�!V .t! �.................... C Telephone .J i1().-R3S,'.31_g2. Fax,,f f.O.'.fbY....1-7...7..Z.. Email......................................................... 2. Material Testing Firm ....................... ..tt Addr............. ........................................................ ................... City.......................... t.�............................................................. J. (........ State ......................Zip ...................... Telephone.......................................Fax............................................ Email......................................................... 3. Geotechnicallnspections Firm .......... ........................................................... Addr......................................................................................... City.......................................................................................................... State .......................Zip Telephone...................................... Fax ............................................ Email......................................................... 4. Other. Firm ...................... ............................................... Addr......................................................................................... City.......................................................................................................... State .......................Zip ...................... Telephone...................................... Fax............................................ Email......................................................... *All agencies specified on this form must be pre -approved and listed on the City of Cupertino's Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Section 1705,3: The extent of the seismic -force -resisting system is defined in more detail in the construction documents. 1705.4.'1 Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind -farce -resisting system and wind resisting components is defined in more detail in the construction documents. SpecialnspectionForm_2012.docrevised 09/06/12 `7 Badr Badding Depatment Cit` Of Cupertino 10300 Torre..venue Cupertino, CA M14-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR J S ONTRACTOR LIST l j .105 ADGRESS_10500 N. De Anza Blvd. PE;RMtL 14120113 - — — OWNER*S NAME:Apple, Inc ------- ------------------- PHONE 4408-862-4397 GENT?RAL C'ON'TRACTOR:Devcon Construction WiSINE SS LICENSE it 11068 ADDRE:SS:690 Gibraltar Dr C 17 Y/ZIPCODI Milpitas CA 95035 `"Our municipal code requires all businesses working in the cite to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCtJMNCY INSPECTION(S) WILL BE: SCHEDULED UNTIL 'hHF. ,;ENERAL CONTRACTOR AND ALL SUBCON'T'RACTORS HAVE OBTAINED A CITY OF C'UPERTINO Bt!SINESS LICENSE. am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: ^✓ SUBCOtiTRACTOR� BUSINESS NANVIE BUSINESS LICENSE # Cabinets & Millwork Cement Finishing x Electrical Redwood Electric Group (d g Excavation renting I _-- x Flooring! Carpeting Bayside Interiors 1-11101CLllll / Wood x Glass l Glazing Grand Prix Glass Heating Insulation Landscaping II Lathing Masonry x Painting / Wallpaper Magnum Drywall Davin ----------- --- Plastering PlUniblllg Roofing Septic Tank Sheet Metal x Sheet Rocl< Magnum DrywallY'�' --- rllt- --- -� - - - - - �1►s Owner / Contractorr Signature Date M `A