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15010066CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22449 CUPERTINO RD CONTRACTOR: BELFOR PROPERTY PERMIT NO: 15010066 RESTORATION OWNER'S NAME: SUNNYVIEW LUTHERAN HOME 2297 RINGWOOD AVE DATE ISSUED: 01/12/2015 OWNER'S PHONE: 6263002440 SAN JOSE, CA 95133 PHONE NO: (408) 929-3473 1 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL SUNNYVIEW - INTERIOR SHEETROCK REPAIR ON ALL 3 License Class Lic. # CONNECTED BUILDINGS DUE TO FLOOD DAMAGE (20 ContractorJZ ,u S Date z1 1 STUDIOS, 4 ONE BEDROOMS, 2 OFFICES, LAUNDRY, 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 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: $200000 ke ormance of the work for which this permit is issued. ave 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: 32615133.00 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 WITIIIN 180 DAYS SSUANCE 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 DA A �ED INSPECTIO . indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses whi may accrue against said City in consequence of the ed by: Date: 2 granting of this pe dditio a applicant understands and will comply with all non -poi . o ce reg Municipal Code, Section 9.18. =ate Signature i i� RE -ROOFS: 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. ❑ O NER-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 (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(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 us uipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by t ay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with upertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, S s 25 33, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized ag Date: '1� S 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 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 a777-3228 • FAX (408) 777-3333 • buildingCcDcupertino.org CUPERTINO (408)4 N* ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI REVISION / EFERRE ORIGINAL PERMIT 4 J501 oO&�o PR07ECf ADDRESS��}..�.}d„/ /+; T� APN # .Z —/33 OWNERN /V 'el2A/J/ M P('ING-6 00 (� IL /�„�i// I VC STREE Z�F C44— ^' FAX CpN1yrT yanrF �0"�/V 1!•V/ /`cJ ri/Jiv�w I i .CII'�Si STREET ADDRESS _ v �fLY, STp SD IP I FAX C�1% �`�= 14 44-10 wo if '❑ `i❑�CONTRACTOR El OWNER OWNER -BUILDER❑ OWNER AGENT ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENNU1 �IBER LICENSE T E BUS. LIC # COMPANY NAME L / r 1� FAX 4040 �! / i -i 92 V 1 STREET ADDRESS CITY, STATE, I / t Veif7-3 A RT E&WEER NPME �&Z LICE ' E E BUS. LIC # zt� CO(M�P 'AME � -7 FAX 3l STRE ADDRESS quY, STATE. ZIP �/ 3 ZI1f PHONE DESCRIPTION OF WORK E7:ISTING USE PROPOSED USE CONSTR. TYPE I STORIES I USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO 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 C3 ATTACH # DWELLING UNITS: IS A SECOND UNrr ❑ YES SECOND STORY [I YES -- BEING ADDED? ❑NO ADDITION? ❑NO PRE -APPLICATION ❑ YES IF YES, PROY6E tOPY OF IS THE BLDG AN ❑ YES - UATION: PLANNING APPL �- ❑ NO PLVAL LETTER EICHLER HOME? ❑ NO By my signature below, I certify t e of the followin I am the property owner or authorized agent to ac on the prope wner's behalf. I have read this application and the information I rovided ' torr ct. have read the Desc iption of Work and verify it rate:^I agree to comply with all applicable local ordinances and state laws relati to it ino c It" io author' e r prese t es of Cupertino to enter the above! -identified property for in on purposes. Signature ofApplicant/) Date: ©( �" l Z _\ SUPPLEMENTAL rNTFO N REQUIRED HECK-,TITE "_ � ouruac°sL>P New SFD or Multifamily dvv'ellings: Apply for demolition permit foro«R TrcouhTER 4 �tBuuDImePLAN12EVIE4v existing building(s). Demolition permit is required prior to issuance of building s permit for new building. Q EXP ZESS -: F r PI.nT'11mGpLn,NREVIEw _ gcompleted _ Commercial Bldgs: Provide a 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 t _ submittal of Building Permit application. _ ❑#SAI�TTARYSE:R'ERDISTRICT->F BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO IOWA >WFF rcTIMATnR - IRT TTI,DING DIVISION NOTE: This estimate does not include fees due to other Departments (i.e. rianntng, ruauc rr urns, 1 sic, ..an..M, .�•.. �•�•• • •, -- _. ,. ... _ pre _ :__ __.:._� _......:.... ......L.6t., ...,d — ..A, nn octimato_ Contact the Debt for addn'l info. District, etc . These Lees are oasea on theunu..0. FEE ITEMS (Fee Resolution 11-053 Ef: 7f 1%13) 22449 CUPERTINO RD DATE: 04/24/2015 REVIEWED BY: MELISSA IQADDRESS: APN: 32615113 BP#: *VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: Commercial Building Civil / Religious activities in BQ zone? © Yes O No PENTAMATION 1 GENCOM PERMIT TYPE: i WORK 4/24/15 - DEF # 1 - UPDATE/REVISE PLANS FOR SITE ACCESSIBILITY SCOPE NOTE: This estimate does not include fees due to other Departments (i.e. rianntng, ruauc rr urns, 1 sic, ..an..M, .�•.. �•�•• • •, -- _. ,. ... _ pre _ :__ __.:._� _......:.... ......L.6t., ...,d — ..A, nn octimato_ Contact the Debt for addn'l info. District, etc . These Lees are oasea on theunu..0. FEE ITEMS (Fee Resolution 11-053 Ef: 7f 1%13) Vech. Plan C?; "iroub. Plan Check CC. Plan Check ,. Plumb. Permit Fee.' I F,lec. Permit Fee' Other Heck Inch MierPlumb 7nsP.Ll L_ deer Elec. Insf El aleck. 1nsP. Fee: Vice. Insz>. Fc ,. $0.00 PME Plan Check: $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. rianntng, ruauc rr urns, 1 sic, ..an..M, .�•.. �•�•• • •, -- _. ,. ... _ pre _ :__ __.:._� _......:.... ......L.6t., ...,d — ..A, nn octimato_ Contact the Debt for addn'l info. District, etc . These Lees are oasea on theunu..0. FEE ITEMS (Fee Resolution 11-053 Ef: 7f 1%13) ...•......•.... FEE » _ -, - QTY/FEE ---__ ___ MISC ITEMS Plan Check Fee: $0.00 1 # $286.00 Deferred Submittal 1DEFSUBM Supp/. PC Fee: Q Reg. ®OT f 07 01 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: 1BCONSTAXC $0.00 Llrtti%tis rulily Pc� " E) Work Without Permit? © Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure O Strong Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $286.00 TOTALFEET $286.00 Revised: 04/01/2015 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(c)cupertino.org F-1 NEW rYINSTRr1r'Tinm F-1 ADDITIOW I ✓I ALTERATION / TI F— REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 2n` 44 t C.O�/�J I ^ WAD APN # c) J��� WL OWNER NAME >tdkN N /y�� �"u�HO E E-MAIL 47A-27a&V2N e-7 5D i STREET ADDRESSSTATE, ZIP FAX X70 0 �- CITY 1-U -r—E� . q c'1 3) ---_ CONTACT NAMEPHONE W/+ A G 300 E-MAIL -0J C t tJ N o STREET ADDRESS .2 e �fl D CITY, STATE, ZIP 4E2 -.L -t o Ar TC C44%. 4 t ^7 31 FAX ^%e/ .=I vqhr_ ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # _ Z Z, E vl S o COMPANY NAM 2 MAILFAX �a o„v tv „Jc;, .� STREET ADDRESS CITY, STATE, JIP qS � 3 / yr � �3 7 .✓ w � Oso. ARCHITEC GINEER E LICENSE NUMBER C 7 BUS. LIC # COMPA AME E-MAI�h FAX �”- EZ ti Yt1�v !/h qv(i ST T ADDR SS, AVE/V C TATE, I �0 /� 'HON E ' n G 0 DESCRIPTION OF WORK ;4-�,c- 3Jlt.D►n7C�. EXISTING USE PROPOSED USE CONSTR. TYPE I # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO 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 # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED! []NO ADDITION' []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING APPL # ❑ NO PLANNING APPROVA LETTER IS THE BLDG AN ❑ YES EICHLER HOME' ❑ NO TOTAL VALUATION: L^�UATION: ' ) �V, Q O V By my signature below, I certify to eac a following: I the property owner or authorize erty owner's a have read this application and the information I hav o Ided is correct. I av read the Description of Work and ven I Is accurate. I agree to comply with all applicable local ordinances and state laws relating ing co tructio . I au orize representatives of Cupertino to enter the above -identified property for ins�p–acction purposes. / 2 Signature of Applicant/Agent:Date- SUPPLEMENTAL INFOPdATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER ❑ BUILDING 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 ❑ 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 iittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp 2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Hire, sanitary sewer ulstrict, 3cnool t, ,vM on f1w .,rerun; -g ;nlnrm"finn available and are onlv an estimate. Contact the Dept for addn'l info. D sii,a r«.. .,," « .­ ..... I FEE ITEMS (Fee Resolution 11-053 Eff 7/1 13) ADDRESS: 22449 CUPERTINO RD DATE: 01/12/2015 REVIEWED BY: MELISSA APN: 326 15 133 BP#: / -VALUATION: 1$200,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial BuildingPENTAMATION 1 GENCOM PERMIT TYPE: A USE: $0.00 PME Plan Check: WORK SUNNYVIEW - INTERIOR SHEETROCK REPAIR ON ALL 3 CONNECTED BUILDINGS DUE TO SCOPE FLOOD DAMAGE (20 STUDIOS, 4 ONE BEDROOMS, 2 OFFICES, LAUNDRY, ELECTRICAL RM & o NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Hire, sanitary sewer ulstrict, 3cnool t, ,vM on f1w .,rerun; -g ;nlnrm"finn available and are onlv an estimate. Contact the Dept for addn'l info. D sii,a r«.. .,," « .­ ..... I FEE ITEMS (Fee Resolution 11-053 Eff 7/1 13) ... I...- - FEE - QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? ® Yes Q No $0.00 l 2 l hours $286.00 Plan Check, Hourly 1STPLNCK Suppl. PC Fee: (F) Reg. 0 OT 0.0 firs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. Fee:Q Reg. Q OT p,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 T_= Construction Tux: Idin inisin dive Fite. 0 Work Without Permit? 0 Yes (F) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure I O � Ooca7nc'w alifm Feces: Strong Motion Fee: 1BSEISMICO $56.00 10.0 hrs $1,430.00 Inspections 1STINSP Inspection, Hourly Bldg Stds Commission Fee: IBCBSC $8.00 SUBTOTALS: $64.00 $1,716.00 TOTAL FEE: 1 $1,780.00 Revised: 01/06/2015 w �, �'-.. - -: ►ice .t rr(L TEMPQRARYCERTIFiCATE OF OCCUPANCY FORM fi ►�'• COMMUNI?Y DC' VS OPME i DEPARTMENT • BULDI ING DIVISION 4�. ALBER-i SALVADOR, P = C.B.O., BUILDING OFr-rIA- R ' I 1 0300 ?OR.RE AV�R71 1 4 JUE - CUPENO, CA 8503%5.5 r \� CUPEP.TINO I (40.3) 77-37-78 FAX (409) 777-3. buildina(c)oupamno.ora f EMPOP ARY CERTIMCA � OF OCCUPANCY 1NFORMAI ION BOND-ry?E,• C7 SURETY BOND '� CODE AMOUNT (1% VALUATION $ �+ ,�scueoNDs) €i CHECK ❑ CASH BOND OF: BOND: 5K min-IOK,ra) �V EDflOht: $ / i TCO cXPIRATtON I / I DAO = RA-11HS MAX): 5 ( TOTAL I ec $?86'.00�riio f =�• Q Oi�0 [i�MPOCC] USE iTYPE 0-r CONST I FLOOR AREA I DAi-: ` j PRCJECT V...LIJAMDtItSIT, E ADDRESS: 2: ^ I i OWNER'S AME:/ -e , v r ` `fz' yt i U RHONE 3L FAX r O (LING AI,DI KESS (s drrer_nt imrnsite address): n� C . �;CT � �p APPROVED i PHONE_: v L _..._ 1..L._...__.. Dai::._..... ........ FAX COMACT: 1 f nPPROVED ❑ APPROVED WI i H CONDI T ;ONS' PHONE ± RAX 9: f EMPOP ARY CERTIMCA � OF OCCUPANCY 1NFORMAI ION BOND-ry?E,• C7 SURETY BOND '� CODE AMOUNT (1% VALUATION $ �+ ,�scueoNDs) €i CHECK ❑ CASH BOND OF: BOND: 5K min-IOK,ra) �V EDflOht: $ / i TCO cXPIRATtON I / I DAO = RA-11HS MAX): 5 ( TOTAL I ec $?86'.00�riio f =�• Q Oi�0 [i�MPOCC] USE iTYPE 0-r CONST I FLOOR AREA I OCC LOAD LEVEL COMMENT i i i �' Cate: APMIII ❑ PROVED WMH CONDONS- 1biiG 1Norr5 � �p APPROVED i I ..... -_-•--��,� ...... L _..._ 1..L._...__.. Dai::._..... ........ OTHER DEPARTMENT 1 AGENCY APPROVALS: IaMlnO f / �1 ❑ APPROVED ❑ APPROVED WITH CONDITIONS' s gnawre:............:__-•-. - _ . _ ........... Cale: ___.._. FIr2 Sianatu = �' Cate: [3APPROVED APMIII ❑ PROVED WMH CONDONS- 1biiG 1Norr5 p � / Q " �p APPROVED El APPROVED WfTri CONDfTIONS' sicnacure: ..... -_-•--��,� ...... L _..._ 1..L._...__.. Dai::._..... ........ nPPROVED ❑ APPROVED WI i H CONDI T ;ONS' `CONDITION'S OF COMPLEDON - Atta n a letter signed bythe contractor a.Rd owner a< the property stating ;.ie list of items required to be completed for each individual Department before final occupancy can be aranied. Include approximate completion dates for each item. i fie undersigned covenant and agree as a mndibor, to The approb'3l of t I_ above re`,.UeS i07 tJ3MD. ors; -y D=pancy to h2ve the builcing or bvridimm—mm01Sia amd lrr rSpl2r -VI tu 11-canr s a it ric� 3 iG� re ilMOMS, and-m-ad+y-ior-inspec5oti- priorm, tie'3�tranai: - dats spe�Iee. If Tsrn c-zry Certmcate of G~rrancy expire_, he amou �f the bond may be Tor it and �e nan compi;ance rnav -esuit in affo niorcemaht acton. I Owner .This temporary wrbncate ensures tai all fire protacton and Iiia safety systems have been =M- ple*-_, irSpecte`', successfully tested andapprove^ for he specific area of the buildinc speaned above to provide - raasonabie degree c safety to he oc.--uparm Trim fire and f simPlar emeroendes. A I dinc, „-iciai:.._. ^ _... ✓r _1.:._.- ............. cri _ _.._._.----.-a. L1�,[_�.---...... Date __.... L .............. Auer deteriir Iauon, cmies tfl. ii/; •�)�el�it, Elie �. .-a - N PERMIT FEE RECEIPT Case # 15010066 Date Printed: 02/22/2016 CUPERTINO CITY OF CUPERTINO - FEES RECEIPT Permit Summary Case Number: 15010066 Permit No: 15010066 Project Valuation: 200000.00 Date Submitted: 01/12/2015 Permit Type: 1 GENCOM Address/APN: 22449 CUPERTINO RD CUPERTINO CA Receipt #: 201530 $572.00 95014 (326 15 133) Scope of Work: SUNNYVIEW - INTERIOR SHEETROCK REPAIR ON ALL 3 Amount CONNECTED BUILDINGS DUE TO FLOOD DAMAGE (20 02/22/2016 SUNNYVIEW LUTHERAN HOME STUDIOS, 4 ONE BEDROOMS, 2 OFFICES, LAUNDRY, $572.00 ELECTRICAL RM & ALL HALLWAYS 4/24/15 - DEF # 1 - UPDATE/REVISE PLANS FOR SITE ACCESSIBILITY **TCO GOOD TILL 1/28/2016** LOCATION: BIN A4 Contact Type: Applicant Full Name: SUNNYVIEW LUTHERAN HOME Address: 3204 ROSEMEAD BLVD STE 100 EL MONTE, C Contact Type: Property Owner Full Name: SUNNYVIEW LUTHERAN HOME Address: 3204 ROSEMEAD BLVD STE 100 EL MONTE, C 02/22/2016 - 11:57:19 AM - Generated by: paulos Fee Information Amount Temporary Occupancy EXTEND TCO FROM 1/28/16 TO 3/28/16 $572.00 Payment Information Payment Date Patron Payment Type Amount Temporary Occupancy 02/22/2016 SUNNYVIEW LUTHERAN HOME Check $572.00 FEE TOTAL AMOUNT PAID BALANCE DUE $572.00 $572.00 $0.00 02/22/2016 - 11:57:19 AM - Generated by: paulos �w �' Lid:: ✓�.i. � -: !✓ J ` w� CL:r EP.TINO TEMPORARY CLER T IFfCATE OF OCCUPANCY FORM COMMUNITY DEVEOPMENT DEPARTMENT - BUILDING DIVISION ALBERT SALVADOR, P_E_ C.B.O., BUILDING OFFICIAL - 10300 T ORRE AVENUE - CUPERT IND, CA 95014-3255 (108) 777-3228 - FAX (408) 77-3-333, buiidingiftuoerano.oro A.'N BP r j DAT--: I PRCJECT VALUATION: . e/ (� OCC LOAD -l�7yY COMMEN7CONl ADDRESS: ADD OWNEP'S AME: (�f�J' �, � PHONE . FAX. , Gr ( ILING ADDRESS ('R dtrierernt horn site address): 7t) i/9 AJTJ__l 1 ! "7 ! , - :....!+.'E._--.1...... Date: 1 G�_:. I� APPROVED PHONE I .. r r ------- FAX 9: =CZ -1 CT: \ ( PHONE r� ) l�fil l✓! % FAX i // 62 i� TEMPOF :RY CERTiFICAt e OF OCCUPANCY INFORMATION 5OND TYPE: ❑ SURE T Y BOND AMOUNT (1% VALUATION � LDSONDS CODE CHECK ❑ CASH BOND OF BOND: 5K min -10K, ,az /C OCD ]' EDITION: TCO EXPIRATIQN f 7 L DATE (6 IRATIHS MMONTAX):�! ZS_ I1 5 FEE: $286.00/mo I TOTAL FEE- S �� <i�C� [f7-EMPOCCI USE I PE OF: I FLOOR AREA OCC LOAD L_EEVEL COMMEN7CONl ubiic %Norrs Signature: \EIAPPROVED i I ....... ?r ..._._.l.Y...1. Dat_: _._._....._. -•-•--. ......-- aicnarura:....._ , - :....!+.'E._--.1...... Date: 1 G�_:. I� APPROVED ❑ APPROVED WITH CONDITIONS' I .. r r ------- OTHER DEPARTMENT / AGENCY APPROVALS: Tanning Sionau re:......_.....; - N/ ` ...... ....... Date: ___-••-- ❑ APPROVED ❑ APPROVED WITH CONDITIONS' `tree ...-........-............:.._..._.__.. Date: .,..._---.....__. Sign-atu, :. ..._ ._ .. [I APPROVED ❑ APPROVED Wi l H CONDITIONS- ubiic %Norrs Signature: \EIAPPROVED ❑ APPROVED WF -1H CONDITIONS` ....... ?r ..._._.l.Y...1. Dat_: _._._....._. -•-•--. ......-- aicnarura:....._ , - :....!+.'E._--.1...... Date: 1 G�_:. I� APPROVED ❑ APPROVED WITH CONDITIONS' .. r r ------- 'CONDITIONS IONS OF COMPLcTION - Asch a letter signed by the contractor and owner a, the property stating the list of items required to be completed for each individual Department before final occupancy can be granted. include approximate completion dates for each item. The undersigned covenant and agree as a condition to the approval of the above request for temporsy o=pancy to have file building or buildings complete and in mofance watt all building odes, ordinances and regulations and ready for inspection prior to Vit- a�irtiar. date specified. t this Tem oary Cermicme of Owupancy a Aires, the otal amoun ,fie bond may be foreited and the non compliance { may result in an`•�nTor�rrz 'action. _ �L i Owner r % ;LV/L�-�;ontrectal / Dat.. Signature:... G` L -1 . •.:L, This temporary certmcaie ensures tial all fire protection and iffe safety systems have been completed, inspecfted, suMessfuiiy 'tested and approved for thc, SPSA' c area 6i the buiidino Sperrnet, above tc provide a e2sonabe degree of safety to the ocouparrs from flree and r similar emergencies. A Buiidinc „rectae: _.... U-� p �- '-k'-�1� ..... ........'_�.._.. ......_.Print .Ll.:?"_t-_- _ 4 DEFAKTMi=NT AMON; Auer determination, copies to: 1) appitcant. -2) permit fie r 16 Tew0c=roar:-201J.doc r&,sed 77174 . 5-7 -,)- ... Joseph Miller Subject: FW: approved /: extension of TCO : SVW Building Permit Expiration Notice From: Albert Salvador [mailto:AlbertSPcupertino.ore] Sent: Thursday, October 22, 2015 2:32 PM To: Martin Lakatos <MLAKATOSPfrontporch.net> Subject: RE: extesnion of TCO : SVW Building Permit Expiration Notice Martin, I spoke with Matt Lopez today and he said he may be ready to submit next week and will call us directly to set up an appointment to do so_ I did approve an extension on your application Regards, Albert Salvador, P.E., C.B.O. Building Official City of Cupertino 10300 Torre Ave. Cupertino, CA 95014 From: Martin Lakatos[mailto:MLAKATOS(d)frontporch.net] Sent: Wednesday, October 14, 2015 11:05 AM To: Albert Salvador Cc: Matt Lopez; 'Esteban Pauli' Subject: extesnion of TCO : SVW Building Permit Expiration Notice Albert, We received yesterday this letter of expiration of out TCO for the Repairs to the flood damage that happened earlier in the year. As you know we have been going back and forth trying to get final stamps of the HCP Upgrades with Andrew on your staff and our Engineers at PAULI, engineers. We will prepare a letter requesting and extension for the TCO today and submit to you for approval. Given that we have been working very hard to get your approval thru plan check on the ADA upgrades imposed on us by the City, we do request you grant us this extension noted on your letter. PAULI Engineers will prepare the formal letter and submit today. Hopefully final plan check approval will be also completed this week. Thanking you in advance for your assistance on this matter and call me if you have any questions 818-266-7387. ITEM 1 OF 1 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32615133.00 DATE ISSUED.......: 11/20/2015 RECEIPT #.........: BS000028793 REFERENCE ID # ...: 15010066 SITE ADDRESS .....: 22449 CUPERTINO RD SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OPERATOR: counterl COPY # : 1 OWNER ............: SUNNYVIEW LUTHERAN HOME ADDRESS ..........: 3204 ROSEMEAD BLVD STE 100 CITY/STATE/ZIP ...: EL MONTE, CA 91731 RECEIVED FROM ....: SUNNY VIEW LUTHERAN CONTRACTOR .......: BELFOR PROPERTY RESTORATION LIC # 32825 COMPANY ..........: BELFOR PROPERTY RESTORATION ADDRESS ..........: 2297 RINGWOOD AVE CITY/STATE/ZIP ...: SAN JOSE, CA 95133 TELEPHONE ........: FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 200,000.00 ---------- 8.00 ---------- 8.00 ---------- 0.00 ---------- 0.00 1BSEISMICO VALUATION 200,000.00 56.00 56.00 0.00 0.00 1DEFSUBM HOUR 1.00 286.00 286.00 0.00 0.00 1STINSP UNITS 13.00 1859.00 1859.00 0.00 0.00 1STPLNCK HOURS 2.00 286.00 286.00 0.00 0.00 1TEMPOCC FLAT RATE 9.00 2288.00 1716.00 572.00 0.00 BLDBONDS FLAT RATE 1.00 10000.00 10000.00 0.00 0.00 TOTAL PERMIT ---------- 14783.00 ---------- 14211.00 ---------- 572.00 ---------- 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- CHECK --------------- 572.00 -------------------- check #5090 TOTAL RECEIPT --------------- 572.00 ITEM 1 OF 1 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN 32615133.00 DATE ISSUED.......: 05/20/2015 RECEIPT #.........: BS000026909 REFERENCE ID # ...: 15010066 SITE ADDRESS .....: 22449 CUPERTINO RD SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNERSUNNYVIEW LUTHERAN HOME ADDRESS 22445 CUPERTINO RD CITY/STATE/ZIP ...: , RECEIVED FROM .... CONTRACTOR .......: COMPANY .......... ADDRESS .......... CITY/STATE/ZIP ... TELEPHONE ........: FEE ID UNIT QUANTITY ---------- 1BCBSC ------------- VALUATION ---------- 200,000.00 1BSEISMICO VALUATION 200,000.00 1DEFSUBM HOUR 1.00 1STINSP UNITS 13.00 1STPLNCK HOURS 2.00 1TEMPOCC FLAT RATE 2.00 BLDBONDS FLAT RATE 1.00 TOTAL PERMIT : OPERATOR: counter COPY # : 1 SUNNYVIEW LUTHERERA BELFOR PROPERTY RESTORATION LIC # 32825 BELFOR PROPERTY RESTORATION 2297 RINGWOOD AVE SAN JOSE, CA 95133 AMOUNT PD -TO -DT THIS REC NEW BAL ---------- ---------- 8.00 ---------- 8.00 ---------- 0.00 0.00 56.00 56.00 0.00 0.00 286.00 286.00 0.00 0.00 1859.00 1859.00 0.00 0.00 286.00 286.00 0.00 0.00 572.00 286.00 286.00 0.00 10000.00 10000.00 0.00 0.00 ---------- ---------- 13067.00 ---------- 12781.00 ---------- 286.00 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 286.00 CHK# 0004827 --------------- TOTAL RECEIPT 286.00 I CUPERTINO TEMPORARY CERTIFICATE OF OCCUPANCY FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building a()cupertino.orq APN 32 �� �?✓-� BP #:te-_o / DOC'��o OCC LOAD DATE: 2 Zvf PROJECT VALUATION: $ �O� Dc�c' SITE ADDRESS: 2'Z4 -'p . .�.!......... Date:...................... t er: Signature: Signature:...... ................... 7 / • _ �. �:!!.:ti. �..... Date: -,/-z "1� APPROVED OWNER'SAME: 'djot,7 R N oma$ PHONE FAX #: — O I N AD ESS (if different from site address): C PHONE #: T;6X0 FAX #: C TACT: PHONE #: 1 FAX #: ZS TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION BLDBONDS CODE CHECK El CASH BOND OF BOND: 5K min -10K max) $ /Q 000 ] EDITION: TCO EXPIRATION DATE X MONTHS MAX): C—/z�/1_5 FEE: $286.00]m0 TOTAL FEE: $ ((J 6 [1TEMPOCC] USE TYPE OF CONSTR FLOOR AREA OCC LOAD LEVEL COMMENT u is Works Q ❑ APPROVED ❑ APPROVED WITH CONDITIONS` Signature: .............. ................. . .�.!......... Date:...................... t er: Signature: Signature:...... ................... 7 / • _ �. �:!!.:ti. �..... Date: -,/-z "1� APPROVED APPROVED WITH CONDITIONS- OTHER DEPARTMENT /AGENCY APPROVALS: anninq Signature :................................................... Date:........................ ❑ APPROVED ❑ APPROVED WITH CONDITIONS- ONDITIONS`i 7re Signature:.............................. il .................. Date:........................ []APPROVED ElAPPROVED WITH CONDITIONS' u is Works Q ❑ APPROVED ❑ APPROVED WITH CONDITIONS` Signature: .............. ................. . .�.!......... Date:...................... t er: Signature: Signature:...... ................... 7 / • _ �. �:!!.:ti. �..... Date: -,/-z "1� APPROVED APPROVED WITH CONDITIONS- *CONDITIONS OF COMPLETION - Attach a letter signed by the contractor and owner of the property stating the list of items required to be completed for each individual Department before final occupancy can be granted. Include approximate completion dates for each item. The undersigned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or buildings complete and in mpliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration date specified. f this Temlrary Certificate of Occupancy expires, the total amoun the bond may be forfeited and the non-compliance may result in a nfor t action. Owner -Contract r� Signature:.,. ... Ai . Date:..y". `l. �l. .. $ignatur •. V4 ... .. ........... Date:..1} This temporary certificate ensures that all fire protection and life safety systems have been completed, inspected, successfully tested and approved for the specific area of the building specified above to provide a reasonable degree of safety to the occupants from fire and similar emergencies. 4 Buildina Official: ...... 1/1 AA ... . . .......................Print:. .... ....... A .T..................Date-.....7.1 ----- DEPARTMENT ACTION: After determination, copies to: 1) applicant, -2) permit file TempOccFonn_2013.doc revised 717114