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14050142 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20955 STEVENS CREEK BLVD CONTRACTOR:ERIC F ANDERSON INC PERMIT NO: 14050142 OAVNER'S NAME: WEISS PAUL E AND BARBARA H TRUSTEE 1066 BEECHER ST DATE ISSUED:08/04/2014 OWNER'S PHONE: 5103849939 SAN LEANDRO,CA 94577 PHONE NO:(510)430-8404 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL {� WHOLE FOODS T.I. -(REVISED SCOPE OF WORK) License Class 1� Lie.4 g`��4� RECONFIGURE (E)CULINARY CENTER TO CREATE(N) Contractor L' ( Gv$OnlXrDate_ to/� SODA FOUNTAIN &JUICE DEPT.REMODELIRECONFIGURE(E) I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions 8/20/2014-DEFERRED#1 REFRIGERATOR COOLER-ISSD 10/2/2014 Code and that my license is in Bill force and effect. 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$387000 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 APN Number:32631022.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 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 FROM LAST 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 source regulations per the Cupertino Municipal Code,Section 9.18. .�J RE-ROOFS: Signature � � V Date ! 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 1 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) 1,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 1 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 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 I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec t in nr3T33,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this f 0/2_1 permit is issued. Owner or authorized agent: 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,1 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the 1 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE- CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333• building a5cuoertino.org CUPERTINO f ' /[1� El NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT, ' Q 7 a PROs DRESSGy-za- APN 9 OWNERNAME PHONE E-MAIL Koki EonJll VID CA -r STREET ADDRESS CItSTATE,ZIP FAX �, v CONTACT Ndk— PHONE (C( � E-MAT. STREET ADDRESS O' l J _ /,/ CITY,STATE, ZIP FAX ❑ OWNER ❑ OUTIER-BUILDER ❑ 0`WNERtAAG•ENf T ❑ CONTRACTOR ❑CON'TR4CTOR AGENT ❑ ARCFi'li-r.CT ❑ENGLN'E�t ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE�`UMBER' O I LICENSE TYPE BUS.LIC R LA COMPANY NAM' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE } -Z'—'" L2Y ARC ENGIN ER. ' 4E LICE N'SEN'UMBERd,��j4Q� BUS.LIC COMPANY NAME na }�yl LI E-MAIL ✓ FAX STREET ADDRESS CITY,STATE,ZI I PHONTE O J D / �a Y-)-yr py)c tscl- DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR PPE :STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXLSTG NEW FLOOR DE1,40 TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ATTACH R'DWELLTNGUNITS: 15.4 SECOND UNIT ❑YES SECONDSTORY [ YTS BEII.'G.+.DDED? ANO ADDITION? ❑No —PRE-A�PLIGtTION—[�-1'ES--Ir Y-ES.�AO-lmEtA2L'OF SSFiF�$1sAG.�.N rl 1'ES ��E��j�le TXMND"-� � _ '� ^rt `�-. •`- TAV PPLANGAPPROVALLETET , - nd ��k•- �. By my sienature below,I certify to each of the fol lowing: the r erty owner or authorized agent to act on the property owner's behalf. I hall read this application and the information I have provided is coil i. I ha ead e Description of Work and verify it is accurate. I armee to comply with all'applicable local ordinances and state laws relating to build st ction. I horiz representatives of Cupertino to enter the above-iden led prop , f inspection purposes. Signature of Applicant/Agent: Date: P� SUPPLEMENT INFOR_MATIONRE UIRED �' �� - Q Ml� L�3?CHECK TI PE# W10 ROU3TI�.Cz OLTP c New SFD or Multifamily dxvellings: Apply for demolition permit for " p existing building(s). Demolition permit is required prior to issuance of building 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. _Copy of Planning Approval Letter or Meeting with Planning prior to Y = 7❑ iP Y0 �1 3`.R iSE44. DISTRI ,.. submittal of Building Permit application. V { t;'tom•."_ ."s_ »,a, �S�'q=v_ :E?�_� I�T1.E2�I fIE 1"Ar+_4 i!. BldgApp_201 1.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 20955 scb DATE: 08/20/2014 REVIEWED BY: Mendez APN: BP#: "VALUATION: Iso 'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION 1GENCO i USE: PERMIT TYPE: WORK deferred #1 refrigerator cooler SCOPE NOTE: This estimate does not include fees due to other Departments(Le. Planning,Public Works, Fire,Sanitary Sewer District,School District, e1G). Thesefees are based on the relimina information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff I'IP13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 14 Deferred Submittal Suppl. PC Fee: D Reg. Q OT0.0 hrs $0.00 $286.00 /DEFSUBA4 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. Fee-G) Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C'.in'Ni il,flolt lai /nmictral"v" h(,c,- 0 Work Without Permit? (:) Yes 0 No $0.00 E) Advanced Planning,Fee: $0.00 Select a Non-Residential G 71".'t I F,('s Building or Structure � i Strong Motion Fee: $0.00 0.0 hrs Inspections Bldg Stds Commission Fee: $0.00 $0.00 Inspection, Hourly SUBTOTALS: $0.00 $286.00 TOTAL FEE: 1 $286.00 Revised: 07/10/2014 -L -PERTiNO CONTRACTOR SU'B(-`ONTR-XCTOR M)N !Css NAME 99,39 (:I \ D\1 AI,CONTRAC FOR: ,�,7- -j:�- C! "C(I u i res a I 1 1)usi k:n��, I n c c 'In "o c LI C� C o cv!i o bu sin(ss lic Our muni6pat Code No MIILDF\(; i 1NA!, OR FINAL OPCCUPANX) PE 'I I N% 01. 1 F, TOR �'Nr) Ai,!- i R HAV- 03-1-31,�F�) OT, 0!! HP B 1 I'�i N FIS S L,C I.-,NS F'. Date pleAso c1lec1: applicable suhcooi ractors and cmilpleii, the fojfm6.11(-, information: SUBCONTRACTOR u U s INN E Ss \A NI E 1 11 U S I N FS S L I( `+ T- Cabinets & Mjlfo-ori, (o 21 Q- C- �-Aca\zition Fc-ncIP11 J.- 6 1 as's layl fit_, ----------- L c-o Insulation .. . ........... IMasolir\ ' 217 painting Wallpaper A Y-) Y-) lv 3) paviw� PILIMbing Roofing —----------- scpticlank Sheet Nitta! shectRock 10 /!)at c Building Department City orcupertlik) 10300 Torre Avenin Cupertino,CA 9501 1 Telephone: 4()8-''7 CUPERTINO F 4 0 - 33 CONTRACTOR SUBCONTR-ACTOR LIST JOB ADDISS: ?_,o gc:;,r PER' ,l 17,4 OWNER'S NAME: ��Z b,014 Fc�_" S— PHONE-9 GENERAL CONTRACTOR: � BUSINESS L.1 C F.'K'S E_ ADDRESS: ohlo� r. 'Z 7 -'Our municipal code requires if] businesses working in the city to have a City of Cupertino business license. NO BUILDING FINA1, OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED uN'r1L THF GENERAL CONTR-ACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CTTV OF CUPERTINO BUSINESS LICENSE. I aim not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information. SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE 9 CabMets& Millwork -32,-��;G 3 -2 Cement Finishing Electrical F3,cavation Fencing Flooring Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping Lathing masonry 9 Painting E Wallpaper Paving Plastering PlUrribingQ c, s)c? Roofing Septic Tank Sheet Metal Sheet Rock L Tile 2Z F! Owncr� 6tor Signature CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20955 STEVENS CREEK BLVD CONTRACTOR:ERIC F ANDERSON INC PERMIT NO: 14050142 OWNER'S NAME: WEISS PAUL E AND BARBARA H TRUSTEE 1066 BEECHER ST DATE ISSUED:08/04/2014 OWNER'S PHONE: 5103849939 SAN LEANDRO,CA 94577 PHONE NO:(510)430-8404 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMiNIERCIAL WHOLE FOODS T.I.- (REVISED SCOPE OF WORK) License Class Lic.4 RECONFIGURE (E) CULINARY CENTER TO CREATE(N) SODA Contractor C t./G /J"A)A,/A C. Date �� FOUNTAIN & JUICE DEPT. REMODEL/RECONFIGURE(E) I hereby affirm that I am licensed under the provisions<f 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 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 erformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$387000 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 APN Number:32631022.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED (_VoRorrect, 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 FROM LAST 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. Ad Hy e applicant understands and will comply Issued by: / v /�'i� Date: with all non Point source ations p e Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date y� 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 I,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(See.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 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 i uality Management District I performance of the work for which this permit is issued. will maintain compliance with the Caper o N . al Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25 2 an 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized agent: Dater 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,f 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 ` v CUPERTfNO (408)777-3228•FAX(408 777-3333•building(a cupertino.org �"\ [INEW CONSTRUCTION [I ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS 20955 STEVENS CREEK BLVD W-S-1-022 OWNER NAME PHONE E-MAIL WHOLE FOODS MARKET 510-384-9939 CLAIR.ROSE@WHOLEFOODS.COM STREET ADDRESS CITY, STATE,ZIP FAX 5980 HORTON STREET SUITE 200 EMERYVILLE CA 94608 510-428-7410 CONTACT NAME PHONE E-MAIL JONATHAN LIEN 415-788-6606 JWL@FIELDPAOLI.COM STREET ADDRESS CITY,STATE, ZIP FAX 150 CALIFORNIA STREET SAN FRANCISCO CA 94111 415-788-6650 ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT VARCnITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC N STEVE REZENDES 82540 B 23223 COMPANY NAME E-MAIL FAX ERIC F ANDERSON, INC(EFA) STEVER@EFA.COM 510-553-7808 STREET ADDRESS CITY,STATE,ZIP PHONE 1066 BEECHER ST SAN LEANDRO CA 94577 510-430-8404 ARCHITECT'ENGTNEER NAME LICENSE NUMBER BUS.LIC N BILL BRIGHAM C-21698 COMPANY NAME E-MAIL FAX FIELD PAOLI WEB@FIELDPAOLI,COM 415-788-6650 STREET ADDRESS CITY,STATE,ZIP PHONE 150 CALIFORNIA STREET SAN FRANCISCO CA 94111 415-788-6606 DESCRIPTION OF WORK G � N 5ifI WFEXISTING CULINARY CENTER,SEATING AREA,CASH ROOM.NEW TAPROOM,JUICE DEPARTMENT AND REMODEL OF 1>✓ SEATING AREA EXISTING USE PROPOSED USE CONSTR.TYPE0 STORIES M-GROCERY STORE N/A V-A 2 USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL GROCERY AREA AREA AREA 1336 SF NET AREA 75.634 WHOLE STORE NO CHANGE NO CHANGE STORE V-A M 1336 $387,000.00 BATHROOM KITCHEN OTHER REMODEL AREA N/A REMODEL AREA N/A REMODEL AREA 1336 SF PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH N/A 'I N/A N/A ❑nTr c" N DWELLING UNITS: IS A SECOND UNIT S SECOND STORY S N/ABEING ADDED? VNO ADDITION? 0 PRE-APPLICATION S IF YES,PROVIDE COPY OF IS THE BLDG AN EI TOTAL VALUATION: PLANNING APPL# NO PLANNING APPROVAL LETTER EICHLER HOME? YrN $387,000.00 By my signature below,I certify to each of the following: I am the property owner or au o on the pr o I have read this application and the information I have provided is correct. i have re e Description of Work and verif te. I agree to comply with all applicable local ordinances and state laws relating to building con tion. I authoriz resentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: 5/23/2014 SUPPLEMENTAL TNFORON REQUT PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: pply for demolition permit for ❑ ovER-TtIE-couNTER ❑ BUILDING PLAY REVIEW 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 ❑ FIRE DEPT ON Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER][STRICT submittal of Building Permit application. ❑ EYVIRONNIENTAL HEALTH B1dgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 20995 STEVENS CREEK BLVD DATE: 05/23/2014 REVIEWED BY: MELISSA APN: 326 31 022 BP#: *VALUATION: 1$387,000 'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY PENTAMATION USE: Commercial Building PERMIT TYPE: 1 M T� WORK FOODS T.I. - RECONFIGURE E CULINARY CENTER TO CREATE N TAPROOM & SCOPE ��HOLE UICE DEPT. REMODEL/RECONFIGURE (E) SEATING AREA (1,336 S.F) OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. M (Tenant Improvements) II-A,111-A,V-A 1,336 $3,589.47 1jVITIPLNCK $1,589.66 IMTIINSP TOTALS: 1,336 $3,589.47 $1,589.66 MECH,HOURLY O Yes 0 No PLUMB, HOURLY Q Yes Q No ELEC, HOURLY Q Yes Q No F-1 Ir,.;, 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 prelimina information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution II-053 Ed. 7/I/I3) FEE QTY/FEE MISC ITEMS Plan Check Fee: $3,589.47 Select a Misc Bldg/Structure Suppl. PC Fee: Q Reg. 0 OT 0.0 I hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $1,589.66 SuppL Insp. Fee-0 Reg. ® OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tux. ;zfmnristr.�tirr Tta;: Work Without Permit? Yes E) No $0.00 (F) Advanced P.laj Fee: $0.00 Select a Non-Residential E) Building or Structure i Strong Motion Fee: IBSEISMICO $81.27 Select an Administrative Item Bl&),Stds Commission Fee: IBCBSC $16.00 SUBTOTALS: $5,276.40 $0.00 TOTAL FEE: $5,276.40 Revised: 04/01/2014 CERTIFICATE OF ACCEPTANCE LTG-2A Lighting Control Acceptance Document (Pae 1 of 3) Project Name/Address: Whole Foods Market(Juice&Soda Fountain )20955 Stevens Creek Blvd. Cupertino, Ca. 95014 System Name or Identification/Tag: System Location or Area Served: Lighting Control/EMS System Juice and Soda Fountain Enforcement Agency: Permit Number: 14050142 Note: Submit one Certificate of Acceptance for each system that Enforcement Agency Use: Checked by/Date must demonstrate compliance. FIELD TECHNICIAN'S DECLARATION STATEMENT a I certify Linder penalty of perjur7.under the laws of the State of California,the information provided on this form is true and correct. a 1 am the person who performed the acceptance requirements verification reported on this Certificate of Acceptance(f=ield"technician). a 1 certify that the constructionlinstallation identified on this form complies with the acceptance requirements indicated in the plans and specifications appro%ed by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. • 1 have confirmed that the Installation Ccrtificatc(s)for the constructionlinstallation identified on this form has been completed and is posted or made availahic with the building permit(s)issued for the building. Company Name: H.A. Bowen Electric Inc. Geld`rechnician's Name: r d echnician's Signature: Brian Ludwig Date Signed: Position With Company(Title): 10/7/2014 Certified Electrician ( Foreman ) RESPONSIBLE PERSON'S DECLARATION STATEMENT a 1 certify under penally of perjury,under file laws of the State of California,that I am the Field Technician.or the Field"technician is acting Oil my behall'as my,employee or my agent and I have reviewed the information provided on this form. a i am a licensed contractor,architect.or engineer,who is eligible under Division 3 of the Business and Professions Code,in the applicable classification,to take responsibility for the scope of work specified on this document and attest to the declarations in this statement (responsible person). a I certifv that file information provided on this form substantiates that the construction/installation identified on this form complies with the acceptance ntquirements indicated in the plans and specifications approved by the enforcement agency,and conforms to the applicable acceptance requirements and procedures specified in Reference Nonresidential Appendix NA7. a 1 have confirmed that the Installation Certificate(s)for the construct ion/i nsta I lation identified on this form has been completed and is posted or made available with the building permit(s)issued for the building. a 1 vvill ensure that a completed.signed copy of this Certificate of Acceptance shall be posted,or made available with the building permit(s) ksued for the building.and made available to the enforcement agency for all applicable inspections. i understand that a signed copy of this Certificate of Acceptance is required to be included with the documentation the builder provides to the building owner at occupancy. Company Name: Phone_ H.A Bowen Electric Inc. 510-483-0500 Responsible Person's Name: Responsi lePerson's. ' ture: Michael Boehmer License: Date Signed: Positio \\`ith Company ): w CA 384915 10/7/2014 Vice President Occupant Sensor,Manual Dayfighting Control,and Automatic Time Switch Control Intent: I Lights are turned off when not needed per Section 119(d)& 13 I(d). Construction Inspection 1 Instrumentation to perform test includes.but not limited to: X a. Hand-held amperage and voltage meter b. Power meter continued on next page 2008:\'onresicienlial,acceplattce Forms Aiignsl 2009 CERTIFICATE OF ACCEPTANCE LTG-2A Lighting Control Acceptance Document (Pace 2 of 3 Project Name/Address: Whole Foods Market(Juice&Soda Fountain)20955 Stevens Creek Blvd.Cupertino Ca. 95014 System Name or Identification/rag: System Location or Area Served: ,Ughting Control 1 EMS System Juice&Soda Fountain 2 Occupancy Sensor Construction Inspection N/A ❑ Occupancy sensor has been located to minimize false signals ❑ Light meter ❑ Ultrasonic occupancy sensors do not emit audible sound(119a)5 feet from source 3 Manual Daylighting Controls Construction Inspection N/A 07 If dimming ballasts are specified for light fixtures within the daylit area,make sure they meet all the Standards requirements,including"reduced flicker operation"for manual dimming control systems 4 Automatic Time Switch Controls Construction Inspection a. Automatic time switch control is programmed for(check all): Existing System ® Weekdays ® Weekend ® Holidays b. Document for the owner automatic time switch programming(check all): Existing Verified o Weekdays settings la Weekend settings o Holidays settings ® Set-up settings o Preference program setting ® Verify the correct time and date is properly set in the time switch ® Verify the battery is installed and energized ® Override time limit is no more than 2 hours Occupant Sensors and Automatic Time Switch Controls have been certified to the Energy Commission in ® accordance with the applicable provision in Section 119 of the Standards,and model numbers for all such controls are listed on the Commission database as Certified Appliance and Control Devices A. Select Acceptance Test(Indicate lighting control systems Names/Designations by the applicable tests below) ❑ 1 Occupancy Sensor ❑ 2 Manual Daylighting Controls ® 3 Automatic Time Switch Controls B. Equipment Testing Requirements Applicable Lighting Check and verify those items applicable to selected system: Control Systems Occupancy Sensor-Step 1:Simulate an unoccupied condition N/A l 2 3 Lights controlled by occupancy sensors turn off within a maximum of 30 minutes from a' start of an unoccupied condition per Standard Section I 1 d Y/N Y/N Y/N b The occupant sensor does not trigger a false'on"from movement in an area adjacent Y/N Y/N Y/N to the controlled space or from HVAC operation c. Signal sensitivity is adequate to achieve desired control Y/N Y/ Occupant Sensor-Step 2:Simulate an occupied condition N/A a. Status indicator or annunciator operates correctly Y/N Y/N Y/N Lights controlled by occupancy sensors turn on when Immediately upon an occupied b' condition OR this requirement is mutual) exclusive with Ste 2.c. Y/N Y/N Y/N c. Sensor indicates space is'occupied"and lights turn on manually Y/N Y/N Y/N continued on next page 2008 Nonresidential Acceptance Forms August 2009 CERTIFICATE OF ACCEPTANCE LTG-2A Lighting Control Acceptance Document (Page 3 of 3) Project Name/Address: Whole Foods Market(Juice &Soda Fountain )20955 Stevens Creek Blvd System Name or Identification/Tag: System Location or Area Served: Lighting Control/EMS System --7Juice&Soda Fountain Occupant Sensor-Step 3:System returned to initial operating conditions N/A Y/N Y/N Y/N Occupant Sensor-Step 4-Sensor is also a multi-Level Occupant Sensor used to qualify for a Power Adjustment Factor in Section 146(a)2D of the Standards. If yes,then'a,' 'b,' Y/N Y/N Y/N and`c' must also be yes. a The first stage activates between 30 to 70%of the lighting either manually or Y/N Y/N Y/N automatically. A reasonably uniform level of illuminance is achieved by dimming of all lamps or b. luminaires;or by switching alternate lamps in luminaires,alternate luminaires,or Y/N Y%N Y IN alternate rows of luminaires. After the first stage occurs,manual switches have been provided to activate the C. alternate set of lights,activate 100 Io of the lighting power,and manually deactivate all 1' N Y?N Y/N of the lights. NIanual Daylighting Controls-Step 1: Manual switching control N/A a. At least 50%of lighting power in daylit areas is separately controlled from other lights Y/N Y/N Y;N b. I The amount of lieht delivered to the space is uniformly reduced Y/N Y/N Y N Manual Daylighting Controls-Step 2: System returned to initial operating conditions N/A Y/N Y/N Y!N Automatic Time Switch Controls-Step 1:Simulate occupied condition ct. All lights can be turned on and off by their respective area control switch y a N Y/N Y/N Verify the switch only operates lighting in the ceiling-height partitioned area in which b. the switch is located /N 1'/N 1 !N Automatic Time Switch Controls-Step 2: Simulate unoccupied condition a. All non-exempt lighting turn off per Section 13l(d)l2 N Y/N Y/N 1. Manual override switch allows only the lights in the selected ceiling height partitioned b. space where the override switch is located,to turn on or remain on until the next N Y/N Y/N scheduled shut off occurs C. All non-exempt lighting turns off N Y/N Y i N Automatic Time Switch Controls-Step 3:System returned to initial operating conditions N_ Y/N Y IN ,Tote:Shaded areas do not apply for particular test procedure f i C. PASS/FAIL Evaluation(check one): PASS:All applicable Construction Inspection responses are complete and all applicable Equipment Testing Requirements responses are positive(Y-yes) FAIL:Any applicable Construction Inspection responses are incomplete OR there is one or mare negative(N-no) p responses in any applicable Equipment Testing Requirements section. Provide explanation below. Use and attach additional pages if necessary. 1008; onresideruial Acceplonce Forms August 2009 INSTALLATION CERTIFICATE (Page 1 of 2) LTG-INST PR0JP,CT NAME: DA CE: Whole Foods Juice& Soda Fountain 10/7/2014 _ 13ROJI CT ADDRESS: Building Permit 20955 Stevens Creek Blvd. Cupertino, CA. 95014 Checkedby?Date Enforcement Agency Ucr GENERAL INFOR:'11ATION DA IT.()F 13111 DING PFR`vIIPriR��it"f-:14050142 8/04/2014 GUILDfNG TYPE ® nonresidential ❑ High-Rise Residential ❑ 1-fotelimotel Guest Room PHASE OF 11 CONSTRUCTION Nc%+ Construction El Addition ® Alteration El Unconditioned if more than one person has responsihility for hrtilding construction, each person shall prepare and sign an Installation Certificate document applicable to the portion of construction for which they are responsible;alternatively, the person with chief responsibilitl•for construction shall prepare and sign the Installation Certificate documenl(si for the entire ``,n+•truction. DECLARATION STATEMENT • 1 certify under penalty of perjur},,under the la%vs of the State of California.the infomiation provided on this form is true and correct- + I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction.or an authorized representative of the person responsible for construction(responsible person). • 1 eertifj that the installed features.materials.components.or manufactured devices identified on this certificate(the installation) conlorms to all applicable codes and regulations,and the installation is consistent with the plans and specifications approved by the enforcement agency. • I revic%+ed a copy of the Certificate of Compliance approved by the enforcement atgency that identifies the specific requirements for the installation. I certify that the requirements detailed on the Certificate of Compliance that apply to the installation have been met. • 1 will ensure that a completed.signed coPy of this Installation Certificate shall be posted.or made available%with the building permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the building o%%tier at occupancy. Company Name: H. A. Bowen Electric Inc. Responsible Person's Name: Respon=-.4j- Lic.# ` i tune: Michael Boehmer Date Signed: Position VVith Compnan9uXZJ- CA 384915 10/7/2014 Vice President SCOPE OF R)E:SPONSIBILITY Electrical Inter the date of approval b'v enforcement agency of the Certificate of Compliance that provides Date: ire spe'cifrcations for the energv q ficiencv nreosures for the scope of responsihrlity for this- Installation hisInstallation C el-tiltcale: In the table below identifi,all applicable construction docurnenis that specy the requirements for the scope of responsibility lbr this hrs•tallaiion Certf ii ate. Date Approved By Document Title or Description Applicable Sheets or Pages,Tables,Schedules,etc. the Enforcement Agency W.F. Stevens Creek Juice&Soda E-1.0 Electrical Symbols,Notes, Schedules, Details W.F Stevens Creek Juice&Soda E-1.1 Electrical Title 24, Key Plan, Notes 2008 Nonresidc nlial Compliance Forms August 2009 INSTALLATION CERTIFICATE (Page 2 of 2) LTG-INST In the table below identify all applicable construction documents that spec6 the requirements for the scope of responsibility reported by this Installation Certificate(continued). Date Approved By Document Title or Description Applicable Sheets or Pages,Tables,Schedules,etc. the Enforcement Agency W.F.Stevens Creek Juice&Soda E-2.0 Electrical Demolition and Lighting Plans, Notes W.F. Stevens Creek Juice&Soda E-3.0 Electrical Enlarged Power Plan,Sched, Notes 2008 Nonresidential Compliance Forms August 2009 CALGREEN SIGNATURE DECLARATIONS Project Name: Whole Foods Market Cupertino- Stevens Creek Prr Address: 20955 Stevens Creek Boulevard pMed pescriow, (N)Bar Taproom & Cooler; Remodel of Seating and Juice Dept SECTION 1 — DESIGN VERIFICATION Complete all tines of Section 1—'Design Vetificafian'and submit the completed checklist(Columna 1 and 2)with the plans and buliding permit application to the Building Department The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated Into the project piens and will be implemented into the project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as adoptm by the City of Cups 04/16/2014 Owner's Signature Date , Clair Rose,Whole Foods Market Northem California Owner Loa Print) / 1 04/18/2014 Design Professbno6_Agnature Date Bill Brigham, Reid Paoli Architects(C21398) 04118/2014 Sign of cense Pro al responsible for Careen compliance Date Big Brigham,Field Paoli Architects(C21398) 415-788-6606 Name of License Professional responsible for CalGreen compliance(Please Print) Phone web@fieldpooli.com Emall Address for license Professlonal responsible for CalGreen compliance SECTION 2- IMPLEMENTATION VERIFICATION Complete,sign and submit the competed checklist,including column 3,together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and Have received suffrdent documentation to verify and certify diet the project identified stove was constructed in accordance with this Green Building Che /dist and in accordance with the requirements of the 2013 Cat Green Building Standards Code as adopted by the City of Cupertino. Signature qLicense Professional responsible for CaKkeen compliance Da '16-7bb-46, Name of License Professional responsible forCaiGreen compliance(Please Print) Phone GPie( a.a i . : . Email Address for L"rcense PrIessional responsible for CaIGreen compliance Page 9 of 9 CalGrem Non-Res Checkistdoc revised OM14