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14070110 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19000 HOMESTEAD RD CONTRACTOR:KAISER FOUNDATION PERMIT NO: 14070110 HEALTH PLAN OWNER'S NAME: ARC KFCPTCA001 LLC 1780 SECOND ST DATE ISSUED:07/24/2014 OWNER'S PHONE: 408851 1000 BERKELEY,CA 94710-1792 PHONE NO:(510)559-5111 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑ 1� SITE WORK TO RE-SURFACE &RE-STRIPE PARKING License Class fl) Lric.# i370 S 7` AREA �C��+.� �� Date Z - Contractor Koi (NO CHANGES IN SPACE OR CONFIGURATION) 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 Zcrformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$250000 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:31609036.19000 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. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 iS A� 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 D S FR LLED 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 Z / granting of this permit. Additionally,the applicant understands and will comply I sue Date: with all non-point source regul is per the Cupertino Municipal Code,Section 9.18. / 7'ZY G RE-ROOFS: Signature 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 I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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). 1 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 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,Sections 21 nd 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:7' u. 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,l CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CONSTRUCTION PERMIT APPLICATION is COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 O CUPERTINO (408)777-3228• FAX(408)777-3333•building a,cupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS 7APN# I! )Q - O 3 a , 9 tin S-ItA IQ p, 9 087 V / OWNER NAME ' PHONE E-MAIL yo'Q 5 -- 1 006 STREET ADDRESS.-. /9 C �i' CONTACT NAME PHONE E-MAIL 7E-MAIL MARK 12-0 S S O y08-595—Y Z 2 �"I AR1l,.04TR Of So 0— C!o• CA STREET ADDRESSCITY,STATE, ZIP FAX 28 K�sP�7at.PH�I'Kw4Y SJ ca 4)51/,7 119 Yo . 3 WNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NA" �^ � J�a,� f}MALL Q.^ J LICENSE NUMBER �� 7 LI wNSE TYPE '� BUS.LIC# �7 ,e/ F� /� COMPANYNAt,�� L•( C E-MAIL ` C� i_! Q R-1 ti t Kp.L� C� FAX U1,23 Iry STREET ADDRESS T12 i CITY,STATE,ZIP n 1-)V r L G /�.A PHONEyV' I/ ARC I TECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# EY S 6'TOF/2A G 2 7 9 3 COMPANY NAME E-MAIL FAX s�.ois serer G 5P9`w01s. NV-- 516s• M.e STREET ADDRESS CITY,STATE,ZIP PHONE 9 M ST o car %YG o 7 Sio - 9.73 -fr8 6 DESCRIPTION OF WORK Mye"fWT- I"N/I4TE7V4AlEC7 ! EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES 2 USE TYPE OCC. SQ FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER A REMODEL AREA REMODELAREA N/k REMODEL AREA N/T PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: DETACH ❑ATTACH N A- N Ai A #DWELLING UNITS: IS A SECOND UNIT ❑YES SECONDSTORY ❑YES N A BEING ADDED? ji[iJO 1fUBIT19" WNG PRE-APPLICATION [:]YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES R [ I JQTA1-VALUATION: PLANNINGAPPLO ❑NO PLANNING APPROVAL LETTER EICHLERHOME? ['NO By my signature below,I certify to each of t follo ing: I am the prope owner or authorized a nt to act pe is behalf. I have read this application and the information I have rovi ed i co I have read t escription of Work and verify it is accurate. I agree to co with all applicable local ordinances and state laws relating I. b Id co t c' . I authori representatives ofCupertino to enter the above' enti led operty for sFection purposes. Signature of Applicant/Agent Date: 2 G SUPPLEMENTAL fNFORMAS TION QUIRE PLAN CHECK TYPE ROUTING SLIP New SFD Or Multifamily dwellings: Apply for demolition permit for ` OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building T permit for new building. ElEXPRESS ElPLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. °-❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEAL BldgApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 19000 HOMESTEAD RD DATE: 07/24/2014 REVIEWED BY: MELISSA APN: 31609036.1900 BP#: v *VALUATION: 1$250,000 SPERMITTYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY PENTAMATION USE: Commercial Building PERMIT TYPE: 1GENC0 i WORK T.I. TO RE-SURFACE & RE-STRIPE PARKING AREA NO CHANGES IN SPACE OR SCOPE CONFIGURATION) Li NOTE: This estimate does not include fees due to other Departments(i e.Planning,Public Works,Fire,Sanitary Sewer District,School District, etc . These ees are based on the reliminar information available and are only an estimate. Contact the Dept-for addn'l info. FEE ITEMS (l=ee Resolution 11-05.3 EfZ. 711U.3) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 1 hours Plan Check,Hourly Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $143.00 ISTPZNCx PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. Fee.'• Reg. 0 OT ro.Q 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 �ne!ructtrfl 7�I.r FT llrriurr�trliii ° PLY: Work Without Permit? C) Yes G) No $0.00 7 E) Advanced Planning Fee: $0.00 Select a Non-Residential 0 Building or Structure �rntsl T7(,r��rc,>>�iatinn 1 ee.� A Strong Motion Fee: IBSEISi'VICO $70.00 = hrs Inspections Bldg Stds Commission Fee: IBCBSC $10.001 $143.00 ISTINSP Inspection,Hourly SUBTOTALS: $80.00 $286.00 TOTAL FEE: 1 $366.00 Revised: 07/10/2014 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C O P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 6 D mes PERMIT# ! l OWNER'S NAME: &PC (J l PHONE# p /00 (7 GENERAL CONTRACTOR: r Co,S r �o it BUSINES LICENSE# ZO `1�7> ADDRESS: 1 T O 10 S+ cC CITY/ZIPCODE: *Our municipal code requires all businesses orking in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 7-2-q4Y Owner/Contractor Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# OWNER'S NAME: PHONE# <$/� GENERAL CONTRACTOR: ' 4/ a UYt BUSINESS LICENSE# ADDRESS: I CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring /Carpeting Linoleum/Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST j JOB ADDRESS: 00 N Ames GG' ' , PERMIT# U70// OWNER'S NAME: AC f'7- Q l 1-,LC PHONE# t, 01 SSI — GENERAL S / —GENERAL CONTRACTOR `- pjt4g,BUSINESS LICENSE# Z 0,67 o ADDRESS: N 79p 2-0- -',+, Q., �,/� CITY/ZIPCODE: *Our municipal code requires all businesses vorking in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL, BE SCHEDULED UNTIL THE { GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE# j Cabinets & Millwork Cement Finishing Electrical Excavation Fencing { Flooring/Carpeting j Linoleum/ Wood Glass / Glazing i 3 Heating Insulation I Landscaping j Lathing Masonry i Painting /Wallpaper i Paving # Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date