B-2017-1596 •
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1596
19376 STEVENS CREEK BLVD CUPERTINO,CA 95014-2526(375 01 018) DILBECK&SONS INC
SALINAS,CA 93912
OWNER'S NAME: RWF INVESTMENTS LLC DATE ISSUED: 10/16/2017
OWNER'S PHONE:831-8830256 PHONE NO:(831)422-8213
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 13 tic.#430708
Contractor DILBECK&SONS INC Date 11/30/2018 X BLDG _ELECT _PLUMB
MECH_RESIDENTIAL X COMMERCIAL
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. JOB DESCRIPTION:
BANK OF AMERICA-TI REPAIR STORE FRONT LIKE FOR LIKE
I hereby affirm under penalty of perjury one-of the following two declarations: (CAR DAMAGE)
1. 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.
_ I have and will maintain Worker's Compensation Insurance,as provided for by
'"s" Section 3700 of the Labor Code,for the performance of the work for which this •
permit is issued. Sq.Ft Floor Area: Valuation:$41000.00
APPLICANT CERTIFICATION
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 APN Number: Occupancy Type:
and state'laws relating to building construction,and hereby authorize 375 01 018
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,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cusertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
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uODate 10/16/2017 •
Issued by:Jasmine Archbold
® Date: 10/16/2017
•
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
r following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
t. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale,(Sec.7044,Business&Professions Code)
2. I,,as owner of the property,am exclusively contracting with licensed Signature of Applicant: _
contractors to construct the project(Sec.7044,Business&Professions Code). Date:10/16/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER•
t. 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements'under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
.3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the t to Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall ,;' 4111i
S
be deemed revoked. • ,1 ' 1 *l•Jr'
,51 5- or authorized agent: � _ — �''"
I l APPLICANT CERTIFICATION 411, e:-10/16/2017
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I a`
gree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the,performance
relating to Building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter uponithe above mentioned property for inspection purposes. (We)agree Lender's Name
to save judgments,indemnify and keep harmless the City of Cupertino against liabilities,
!'Costs,and expenses which may accrue against said City in
Lender's Address •
,
consegdericelof the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signeture_' _- Date 10/16/2017 Professional
.1
CONSTRUCTION PERMIT APPLICATION r
(I COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION - -----,•7-- -• �8
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 •
4 d $�
-tr,s.
s (408) 777-3228 • building@cupertinu.org PEMIT#B-20 t f - 151
CUPERTIPlOREV# DEF#
•❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION VT.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
•
PROJECT AQ :V., ^ cz, N e J Q 03 Qpze,1/44. ,, ls4, APN#
OWNERNAME PH
� ',O),r$� " 2 t N a Dvr%AD��P"-ALL
�M1\ 0'c �c'v-P E-MAIL
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STREET ADDRESS CITY,STATE,ZIP �� �� M�o1I��A
CONTRACTOR NAME ElOWNER-BUILDERCOMPANY NAME LICENSE NUMBER LICE PE
ISTREET A DRESS CITY,S Z '
- AIL I PHONE BUS. I Z✓
❑ARCHITECT ❑OWNER ❑OWNER AGENT ❑CONTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT
CONTACT NAME - E-MAIL
STREET ADDRESS CITY,STATE,ZIP PHONE
DECRIP e'N.I' kV+ cf`bok / ePtr ) .
❑SINGLE-FAMILY/DUPLEX ®MULTI -FAMILY ❑INDUSTRIAL 14OMMERQAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES A TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN ' REMODEL OTHR GARAGE ❑ATTACHED '
BATHROOM SF SF I: II is ' SF SF ❑DETACHED '
F RIEEXSING
SI SPRINKLERS❑YES EICHLEIt I EYES SECOND STORY ADDITION DYES
0 NO . If 1 ,❑ NO 0 NO
DWELLING SECOND DWELLING IbYES ❑ATTACHED 0 DETACHED OTHER
' UNITS a UNIT ADDITON: 1 j i❑NO S F
'
f 9 1
, POOLS' ❑FIBERGLASS ❑NIN!+L LINED D GUNITE ❑PREFABRICATED Ir
POOL-SF SPA-SF •, 1''SPA ATTACHED OYES 0 NO TOTAL-SF Ii
i I1, RE I BY: uV�Vw T aT_VALUAT I
Commercial or Multi-l-dniily Buildings�uttth�I'ubIic Swimming Pools requires Department of Environmental Heath approval ��`r'�, I, ,-
RE-ROOFI EXISTING ROOF,TYPE:I i❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOOD SHINGLES❑ LE OTHER(SPECIFY) 11.
REMOVE/REPLACE❑NO. IF NO'.; PLYWOOD 111 ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
El YES k OF iLAYERS' ' THICKNESS❑5/8" OTHER ❑OSB III CDX OTHER :12 A I1,
PROPOSED ROOF TYPE:❑BUILT-UP ROOF!❑ASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER +1
*Provide a signed copy of the Cupertino's Tear-Off Policy SF #of SQUARES1;
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 is correct. I have read the Description of Work and verify it is accurate. I agree '1'
to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection purposes. I acknowledge and authorize all information contained on this application form
to be made available for public r _
Signature of Applicant/Agent: Date\`‘Ct 1 11 1
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling,Units/Mliltifamily Dwellings:A Demolition permit is'required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval'Lletter or Meeting with Planning prior to submittal'of Building Permit application.
*HOA-Provide a letter of approval from,the Home Owner's Association
i` ' 1 BldgApp_2017.doc revised 08/01/17
iiii, INSPECTIONS, Inc. DSA File#
690 SUNOL STREET, BUILDING H•SAN JOSE, CA 95126 DSA Appl #
(408) 288-8460•FAX: (408) 271-0902FEL - OS H P D #
PROOF LOAD TES 1 -- PORT ti- rs-r6
City of• C f
Date /f- Z- / 7
Project .ame
Addres.: / 7374 5. wc ,, d-c- - L741,-) Permit# /7/--s-?‘
Inspectors Name ( , ; �;t t ID# 4/
e
MMMMM NM
Applied tension proof load (lbs.) /to q load :oot-lbs.) of 4e) to ,"
, � diameter
t ff�. ' � 1+t located in the h TZ,44 t=om -71/ 1.-, c•,p c
8 (No.) anchors of a total of S installed were tested representing / 6 6
with/without apparent visual distress or failure. 0 (No.) anchors failed to meet proof
load requirements. Identified and reported failed anchors toy
at the jobsite for appropriate action.
Notes:
Applied tension proof load (lbs.)/torque load (foot-lbs.) of to diameter
located in the
(No.) anchors of a total of installed were tested representing
with/without apparent visual distress or failure (No.) anchors failed to meet proof
load requirements. Identified and reported failed anchors to
at the jobsite for appropriate action
Notes.
Fla
V. _
Inspectors'signature.! �.. --�
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