14050163 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20558 STEVENS CREEK BLVD CONTRACTOR.-TBD-TO BE PERMIT NO: 14050163
D&TERMINED
OWNER'S NAME: MARDESICH CO CROSSROADS LLC DATE ISSUED:05/29/2014
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E]
/ SPROUTS-T.I PREP 20,986 SQ FT
License Class /� Lie.# J
Contractor Date
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
pe ormance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$200000
1 ave and will maintain Worker's Compensation Insurance,as provided for by
ion 3700 of the Labor Code,for the performance of the work for which this
APN Number:3590801$.20558 Occupancy Type:
ermu 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 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 DAYF-ROM LAST CALLED INSrECTION.
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 ofthis permit. dditionally,the applicant understands and will comply Issued by: Date
with all non-point sour regulations per the Cupertino Municipal Code,Section
9.18.
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). 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 Arca 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
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2 05,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this y ZQ
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 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 r
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333• building(a.cupertino.orq
CUPERTINO
❑NEW CONSTRUCTION ❑ ADDITION LTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROTECT ADDRESS ��"�L"� � P j�, APN# -� � ((( �J
1_7
�j� ( �, /
OWNER NAME '� Il"•d4 P'(� L PfHnO E E-MAIL
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENS UMBER LICENSE TYP BUS.LIC#
Vol
COMPANY NAME E-Y.41. FAX L,/ 1
STREET ADDRESS i5 ��'f! CITY,STATE,Z1P �+ � � PHON /V
ARCHITECT/ENGINEER NAME �'1. LICENSE NUMBER BUS.LIC# D
COMPANY NAME f /r E-MAIL FAX
STREET ADDRESS // , CITY,STATE,7� K Z �� , PHONE
DESCRIPTION OF WORK/ �� -i
EXISTING USE PROPOSED USE CONSTR TYPE #STORIES
USE TYPE OCC. SQ.FT. VALUATION IS)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECKTORCH AREA GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS IS A SECOND UNIT ❑YES SECOND STORY OYES
BEING ADDED" ❑NO ADDITION" ❑NO
PRE-APPLICATION E]YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVE Y: TOTAL VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME" ❑NO .--y1, — . +W
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 information I have provided ,correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bwldin truction. 1 authorize representatives of Cupertino to enter the above-identified pro erty for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENT INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for VER-THE-COUNTER BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building LK
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
submittal of Building Permit application. El MAJOR 70 SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 20558 stevens creek blvd DATE: 05/2912014 REVIEWED BY: mendez
APN: BP#: `VALUATION: 1$200,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION 1TIPREP
USE: PERMIT TYPE:
WORK Sprouts T.I prep 20,986 sq ft
SCOPE
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eft' iil%13} FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Tenant Improvement Prep
Suppl. PC Fee: ) Reg. Q OT 0.0 hrs $0.00 $405.00 ITIPREP
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:(j) Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
0
Work Without Permit? 0 Yes No $0.00 E)
Advanced Planning Fo $0.00 Select a Non-Residential E)
Building or Structure r
Strony, Motion Fee: IBSEISMICO $42.00 Select an Administrative Item
Bldy_Stds Commission Fee: IBCBSC $8.001 1
SUBTOTALS: $50.00 $405.00 TOTAL FEE: 1 $455.00
Revised: 04/01/2014