B-2016-2061 CONSTRUCTION PERMIT APPLICATION �
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
GUPERTINO (408)7773228 • FAX(408)7773333•buildinq(�cuoertino.orq 6�ao« � ao�i
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6c m<signamre belo�c 1 ceniPo tn each of�he tollo�cine: I am Ihe propem'o�cner or aulhorizad aeent Iu aei on the propertv o�mers behal . I have read Ihis
application and Ihe inionnation I have roe'ided is mrrect. I hace read the Description o(N'ork and cerifi'it is aecurale 1 agme tu compl�'�cith all applieable loeul
ordinanees and s�a�e la�cs rela�in¢�o ilding construetion. 1 authorize represematives ntCupertino Io eNer Ihe vboce-idenii�ed pmpem�Ibr inspeciion purposes.
Signalureo(ApplicvnVAeenC Dute: ��'�Q, '�6
SUPPI.IiML=N'I' L INFORMATION RIiQUIREU ����ny� ROlT6G5LIP
Ne�c SPD or Multi(amilc dnellings: Apply for demolition pennil for T7 O�'ER-TH6COl"1TER � BCILDL�G PLAR RE\lEM
e�isting buildingls). Demoli�ion pemiit is required prior to issuanec ofbuilding T
pcnnit far ne�<building. ❑ exr�s5 ❑ %,ASViGPLA.V RE\"IEN
Commercial I31dgs: Pro�ide a completed Hazardous Materials Disclosure ❑ sr.awwxn ❑ PCBLMNORAS
form if am Hazardous\4aterials are being used as part ofthis projecL ❑ ��RGE � nx[ovt
Copy of Planning Approcal Leticr or Mee�ing a-ith Planning prior[o
submittal of Building Pcmiit application. � N'i°a ❑ 5{YfTUt\SENER qSTRIR
❑ E]l'IRO]'NESTAL HE-V.TH
Bldg.-I pp_2077.doc rerised 06?l l l
CITY OF CUPERTINO BUILDING PERMIT
BU[LDING ADDRESS: CONTRACTOR: PERNIIT NO:B-2016-2061
IOIOI N DE ANZA BLVD CUPERTINQ CA 95014(326 34 071) TCG BCiII.DERS INC
MILPITAS,CA 95035
OWNER'S NAME: WATERDRAGON 289 LLC DATE ISSUED:06/02/2016
OWNER'S PIIONE:$10-091-8424 PHONE NO:(408)32L6450
LiCFNcxn rnvrnarrnu�s nFCLnlinTTont BUILDING PERMIT INFO:
License Class 4 Lic.#83 X BLDG _ELECT _PLUMB
ConUactor TCG BUILDERS INC Date 04/30/20'18
D4ECH RESIDENTIALXCOMMERCIAL
I here6y affirm tl�a[t am licensed under[he provisions of Chapter 9(commencing —
with Section 7000)of Division 3 of[he Business&Professions Code and tha[my
license is in Cull force and effect. JOB DESCRIPTION:
APPLE TENANT IMPROVEMENT ON SECOND FLOOR TO ADD
I hereby affirm under penalty of perjury one of[he following hvo declaratlons: VESTBULE AT ELEVATOAS(233 SQ FT).
i. I have and will maintain a certificate of conse�t[o self-insure for Worker's
Compeusation,as provided for by Section 3700 of the Labor Code,for the
pcdormance of the work for which[his pemtil is issued.
]have arid will maintain Worker's Compensatiou Insumnce,as provided Cor by
Sec[ion 3700 of tlie Labor Code,for the perfortnance of Ihe work for which lhis
perrttil is issued. Sq.F[Floor Area: Valuation:$20000.00
1PPLIC 1NT CERTiFICATIO\`
I certify that I have read this application and state fhat the above pp�rumber: Occu anc e:
information is covect.I agree to comply with all city and counfy ordinances P Y TyP
and state laws relating to building consiruction, and hereby authorize 326 34 071 B(Tcnanc Improvemenes)
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
Ciry of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue agairst�aid Ciry in consequence of ihe granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE �R
Ad tiorial�the pplic'a t understands d�i I comply with all non-point
sour re9u� tion� erth c rtino M nicipa�.Code,section s.�e. I 180 DAYS FROM LAST CALLED INSPECTION.
r�
SignaWre � Date fL�t@ Issued by: SEAN HATCH� / �
Date:06/02/2016 �/`l f/f1'/�L�
OW�ER- 7L RDE LA TI�
I herebV affirm[hat I am exemp[fr [he Con[ractor's License Law for one of[he RE-ROOFS:
following 6vo reasons: All roofs shall be inspected prior to any roofing material being installed if a roof is
i. I,as owner of ihe pmperty,or my employees with wages as their sole �nstalled without firs[obtaining an inspec[ioq I agree to remove all new materials for
compeusatioq mill do lhe work,a¢d the swchue is not intended or ofCered!or
inspection.
salc(Sce.7044,Busincss&Profcssians Code)
z. I,as owner of the propeRy,am exclusively contractiug wilh lice�sed �.Signature of ApplicanC
convactors to construct the project(Sec]044,Business&Professions Code). Dare:6/2/16
I hereby affirm under penalry•af perjuq•one of the Collawing three declarations: pI,L ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. I have and will maintain a Certificare of Consent ro self-insure for Worker's
Compeusa[ion,as provided for by Section 3700 of the Labor Code,for the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
a I have and will maintain Worker's Compeusation Insura�ce,as provided for by 1 have read Ihe hazardous materials requirements under Chapter 6.95 of[he
Section 3700 o(the Labor Code,for the pedortnance of[he work for which[his California Health&SafMy Code,Sec[ions 25505,25533,and 25534. I e�tll
emtit is issued. main[ain compliance with the CuperHno D7unicipal Code,Chap[er 9.12 and tM1e
P Health&Safety Code,SecNou 25532(a)should I store or handle hazardaus
n. I certify Utat in the pedonnance of tlie work for which this permi[is issued,[ material. Addi[ionally,shauld I use equipment or devices which emi[hazardous
shall no[employ any person iu any manner so as�o bccome subjec[[o Ihe air confaminan[s as defined by[he Bay Area A'v Quali[y Managemen[District I
R'orker's Compensation laws of Califomia. If,after making this certificate of µ.�p�ain[ain comptiance�4ith E e C � er[ino�lunicipat Co e, hapter 9.12 and
exemption,I become subject m the Worker's Compensation provisious of the the Health&Saf Co �S ons 2 O5,25533�nd�5534.
La6or Code,I must forthwith comply with such provisions or this pertnit shall I '� ��
be deemed revoked. �Owner or authorized agent:
APPLICANTCERTIFICATIOV IDate: 6� � . 1
I certify that I have read this application and state that the above information is O\STRU TIO LE IN A ENCY
correct. I agree to comply with all city and county ordinances and state laws ��I hereby affrm that there is a co uction I nd' g aqency for the pedortnance
relating to building construction,and hereby authorize represenlatives of Ihis city of work's for which this permit is issued(Sec. 097,�C+iv CJ
to enter upon the a6ove mentioned property for inspection purposes. (We)agree I,LendeYs Name
to save indemnify and keep harmless the Cily of Cupertino against liabilities, ��Lender's Address
judgments,costs,and ezpenses which may accrue against said City in
consequence of the granting of this permit. Addifionally,the applicant understands pgCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public rewrds.
Code, Section 9.18.
Licensed
Signature Date SiL2L Professional