B-2017-0444 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0444
19700 VALLCO PKWY STE 130 CUPERTINO,CA 95014(316 20 108) CREATIVE ROOTS
BUILDER
SAN JOSE,CA 95116
OWNER'S NAME: SUSAN SONG(Cupertino Properties Dev I,LLC) DATE ISSUED:08/28/2017
OWNER'S PHONE:408-343-1088 X10 PHONE NO:(408)205-4634
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#872576
Contractor CREATIVE ROOTS BUILDER Date 01/31/2018 X BLDG _ELECT _PLUMB
MECH_RESIDENTIAL X COMMERCIAL
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. JOB DESCRIPTION:
KOJA KITCHEN RESTAURANT T.I.;SUITE 130;(1000 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations: REV#1 REMOVE ONE FLOOR SINK AND RELOCATE ONE FLOOR
1. I have and will maintain a certificate of consent to self-insure for Worker's SINK IN KITCHEN-ISSUED 9/11/2017
Compensation,as provided for by Section 3700 of the Labor Code,for the REV#2 CHANGE GREASE DUCT FROM CAPTIVE AIRE BRAND TO
:erformance of the work for which this permit is issued. CUSTOM-ISSUED 10/09/2017
-itt 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:$100000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above • -
information is correct.I agree to comply:with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 20 108 A(Tenant Improvements),B(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 of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source reg a'ins per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
= e ature Date 10/9/2017 Issued by:Kim Dunbar
Date:08/28/2017
1 . ►r4.:-B LDELDE" D_ •
I hereby a at I ant 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 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: 10/9/2017 -
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 1 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 Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,C• tions 25505,25533,and 25534. ,
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. it or authorized agent:
APPLICANT CERTIFICATION te: 10/9/2017
I certify that I have read this application and state that the above information is CONSTR J CTION r DING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a co- 'ction 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 10/9/2017
Professional
CONSTRUCTION PERMIT APPLICATION
\*,,/ COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
- 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
•
sl:19,, r''(
•4. .r (408)777-3228 • building@cupertino.org PEMIT#B-Ill 1 - 0 i f
CUPERTINO REV# 2 DEF#
•
❑ NEW CONSTRUCTION ❑ADDITION ❑ ALTERATION ❑T.I. '❑MEP' ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS 1\^ Q V \JAI
COI 11 �� APN R
OWNER NAME J l C PHONA 1410 �O %)1t E-MAIL
STREET ADDRESS CITY,STATE,ZIP CC l
1 11 Go �k 4 Vo CJc rkh-o CE A 1S O IN LICENSE TYPE •
�OI�TR�RNAMA�E�V❑�QO�JW�N��ER-BUIL COMPANY � �� Jt1� ����
STREET ADDRESS,1Vw\ V V u V V`¢ CITY,STATE, ZIP I
\4 t SSM -ee,rvw,n&:&o S . r.);44. 1--)t-
1
C� Sl to
E-MAIL PHONEBUS.LIC ttc c sak\ISS a ,�,cdv;, . Aon 205
❑ARCHITECT 0 OWNER ❑O ER AGENT ❑CONTRACTOR AGENT ENGINEER 0 DEVELOPER ❑TENANT
CONTACT NAME E-MAIL
STREET ADDRESS .CITY,STATE,ZIP PHONE _
DECRIPTON
❑SINGLE-FAMILY/DUP-EX ❑MULTI-FAMILY ❑INDUSTRIAL ❑COMMERCIAL I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES I TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
_REMODEL 'REMODEL KITCHEN REMODELOTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING ❑YESEICHLER I=1 YES SECOND STORY ADDITION ElYES
FIRE SPRINKLERS 0 NO ❑ NO ❑NO
DWELLING SECOND DWELLING ❑YES ❑ATTACHED DETACHED OTHER
UNITSI UNITADDITON: ❑NO S F
POOLSI ❑FIBERGLASS ❑VINYL-LINED 0 GUNITE D PREFABRICATED _
POOL-SF SPA-SF "I SPA'ATTACHED 0YES 0 NO I TOTAL-SF
RE EIVED BY: A
rV4Q) TOTAL VALUATION:
Commercial or Multi-Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval ►\A/
r ` r.b
RE-ROOFI EXISTING ROOF;TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO ;IF NO ' PLYWOOD ❑1" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
❑YES :pbOFLAYERS'' THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER ,12 A
PROPOSED ROOF TYPE:ID BUILT-UP ROOF^DASPHALT SHINGLES 0 WOOD SHAKES,❑WOOD SHINGLES ❑OTHER -
*Provide a signed copy of the Cupertino's Tear-Off Policy SF ttof SQUARES
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 iri,• mation 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;".•. ances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified,property,;.,fo .ection purposes. I acknowledge and authorize all information contained on this application form
to be made available for public record. �\
' Signature of Applicant/Agent: G�1 Date: �IV N ,i
SUPPLEMENTAL INFORMATION„ EQUIR D '
*New SFD/Second Dwellii�g'Units/Miil,' y Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter,oiMeeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval<froni the Home Owner's Association '
i 1 BldgApp_2017.doc revised 08/01/17
i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0444
19700 VALLCO PKWY STE 130 CUPERTINO,CA 95014(316 20 108) CREATIVE ROOTS
BUILDER
SAN JOSE,CA 95116
OWNER'S NAME: SUSAN SONG(Cupertino Properties Dev I,LLC) DATE ISSUED:08/28/2017
OWNER'S PHONE:408-343-1088 X10 PRONE No:(408)205-4634
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lie.#872576
Contractor CREATIVE ROOTS BUILDER Date 01/31/2018 X BLDG _ELECT _PLUMB
MECH_RESIDENTIAL Y COMMERCIAL
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. JOB DESCRIPTION:
KOJA KITCHEN RESTAURANT T.I.;SUITE 130;(1000 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations: REV#1 REMOVE ONE FLOOR SINK AND RELOCATE ONE FLOOR
I have and will maintain a certificate of consent to self-insure for Worker's SINK IN KITCHEN-ISSUED 9/11/2017
dirCompensation,as provided for by Section 3700 of the Labor Code,for the
rformance of the work which this permit is issued.
iliohave,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:$100000.00
I APPLICANT CERTIFICATION
I.certify that I have read this application and state that the above
- information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws,relating to building construction,and hereby authorize 316 20 108 A(Tenant Improvements),B(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 of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source.regulation •er the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Sign-?1= n
it„ Date 9/11/2017 Issued by:Kim Dunbar
Date:08/28/2017
9 A;\ Alliir.,_: 11_ I 1 to, "---'--: Z_: I L
I hereby aft' at I am exempt from the Contractor's License Law for one of the BE-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:9/11/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"'OR BETTER
i. 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
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
air contaminants as defined by the.:;y Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the u.•rtino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Se ions 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. -Owner o_.„a^+o`rized age
APPLICANT CERTIFICATION - D E'.ili'I ...„
I certify that I have read this application and state that the above information is CONS 'UC_ 0 ND I ;G .CY
correct.1 agree to comply with all city and county ordinances and state laws . I hereby affirm that there is aa 4 ion 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.
Signature Date 9/11/2017 Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
v 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
,.,;(,..11...,,,,
(408) 777-3228 • building@cupertino.org PEMIT aB- ?/011 - 04414(CUPERTINO REV# l DEF#
El NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESSTV�/ APN tt
1 1/1DJO t� 1 F 4J`I l$i PHONE E \U E-MAIL e
OWNER NAME J
STREET ADDRESS CITY, STATE,ZIP
ElCONTR CTOR NAME (OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE{ TYPE
I - 4�`1'.-(�,'9 -- CjN ki - r t kr c5124110 'STREET ADDRESS V Y,STATE, ZIP I
\iq0 t S - ,ir-iNOAAA 4 Ste. CA- 15116
E-MAIL PHONE BUS.LIC I
c Gree o \Oth `tart, N its if b ►;
•
•
CITY OF CUPERTINO BUILDING PERMIT .,
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0444
19700 VALLCO PKWY STE 130 CUPERTINO,CA 95014(316 20 108) CREATIVE ROOTS
BUILDER
SAN JOSE,CA 95116
OWNER'S NAME: SUSAN SONG(Cupertino Properties Dev I,LLC) DATE ISSUED:08/28/2017
OWNER'S PHONE:408-343-1088 X10 PHONE NO:(408)205-4634
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#872576 -
Contractor CREATIVE ROOTS BUILDER Date 01/31/2018 X BLDG _ELECT _PLUMB-
MECH_RESIDENTIAL X COMMERCIAL
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. - JOB DESCRIPTION:
' KOJAKITCHENRESTAURANT T.L;SUITE 130;(1000 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations: ,
i. 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.
- ave and will maintain Worker's Compensation Insurance,as provided for by
nave
3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$100000.00
APPLICANT CERTIFICATION '
I certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 20 108 A(Tenant Improvements),B(Tenant Improvements)
representatives of this city to enter upon the above mentioned property fori '
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 of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally •e applicant understands and Will comply with all non-point
source reg lati. s per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur; _ Am Date 08/28/2017 Issued by:Kim Dunbar
AprDate:08/28/2017 .
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 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:08/28/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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
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
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 .,ertino Municipal Code,Chapter 9.12 and
exemption,I become,subject to the Worker's Compensation provisions of the the Health&Safety Cod=:Se tions 25505,25533,and 25534.
Labor.Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. , Owner or authorized agent• _
APPLICANT CERTIFICATION Date:08/28/2017 1. ,
I certify that I have read this application and state that the above information is Cs S tr 66 0.J END i G:G C
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a • truction 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 rion-point source regulations per the Cupertino Municipal • ARCHITECT'S DECLARATION
Code,Section'9.18. I understand my plans shall be used as public records.
Signature Date 08/28/2017
Licensed
g Professional