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14050136 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19929 STEVENS CREEK BLVD CONTRACTOR:3;B9--4@-136 PERMIT NO: 14050136 OWNER'S NAME: PANT SUSHMA � i BLIlj 4 DATE ISSUED:06/26/2014 OWNER'S PHONE: 4086553391 P,LIM61M PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ICEBOX T.I. TO RECONFIGURE(E)RESTAURANT 200 S.E. License Class —�� Lic�.# �ZO 17 -7 Contractor &LeM. Date lb—Z6—0 I hereby affirm that l 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. 1 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$20000 l have 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:31621090.19929 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 ED correct.I agree to comply with all city and county ordinances and state laws relating WI HIN 180 �� ®� 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)(DAB'S FRO ALLED IN 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 of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non- vnta ionserupertino Municipal Code,Section 9.1 _ RE-ROOFS: Signature Date v 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 1 hereby affirm that l 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 1,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) 1,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 1 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(x)should l store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 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 255,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this _��_® permit is issued. Owner or authorized ag 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,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 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 l 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 b CONSTRUCTION PERMIT APPLICATION O\ COMMUNITY DEVELOPMENT DEPARTMENT' BUILDING DIVISION ((�� 10300 TORRE AVENUE ^ CUPERTINO, CA 95014-3255 �V (408)777-3228' FAX(408)777-3333^ building a1cupertino.orq \ cCUPERTINO ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS t a S Z,L��►J S G�6C—K ��-v q APN 3 y6 q- 05 03 d I�_ OWNER NAME Fof .A �- �� PHONE iloV �/ ss�3�(11 E-MAIL L��1 �1 iceboy{.�l", Lom 1 vW6 N9A -1 0 b - STREET ADDRESS _ ve,5 STATE,ZIP Jr FAX CONTACT NAME f a/ f( PHONE E-MAIL ' STREET ADDRESS CITY,STATE, ZIP FAX e' 3$_40'1. �L�-v«�+c W4� ST6 S�o.loa � C® 08-� 4og ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ARCHITECT ❑ENGINEER ❑ DEVELOPER El TENANT CONTRACTOR NAME tt> LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC _!V% -p" T, COMPANY NAME E-MAIL FAX sI.n:r,.l-`►a,� 'w,1%11 DSSOe 4aL tnw% (IV`b) 'I S%- U100 STREET ADDRESS CITY,STATE,ZIP PHONE 16'-¢-1 061L��6 Wa,Y� S�t`TE f SVr.+aJ ve�'E� e_� 13 226-1 �4o06 s(. DESCRIPTION OF WORK d, C_M"� SA-0 C (.o"c novliz'i tve[L Fcop '4w."rD .-+tom E cs�E=h.v�n rj•�0 6 ax EXISTING USE PROPOSED USE CONSTR TYPE STORIES V."` '4T_ ,« c_T_I9?1..v1 V Z y USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR ! TOTAL �'y�r�, AREA O AREA A - ®� NET AREA p Z i7O V J BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREATOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ATTACH DWELLING UNITS: ISA SECOND UNIT ❑YES SECOND STORY ❑YES ."GADDED? NO ADDITION? ❑NO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIV x..- ' .;� TCS AL VALUATION: PLANNING APPLNO PLAN'NINGAPPROVALLETTER EICHLERHOME? z t Is- ❑ []NO t �{ isv : ?.17rv0� s By my signature below,I certify to each of the following: I am the property owner or aut nze as erty owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and veri accurate. I ag omply with all applicable local ordinances and state laws relating to buuiilldin�g constru tion. I authorize representatives of Cupertino t n the above-identified prope nspection purposes. Signature of Applicant/Agent: �� T. i Date: Z0'4� SUPPLEMENTAL INFORMATION.REQUIRED � W�PLAI.,CHECxT37E_, _` W_,_,, , .,ROUTII�GSLIP r New SFD or Multifamily dwellings: Apply for demolition pen-nit forE6 �� ❑1 OVER TFI)<COIII�TER BUILDING PLAN REVIEF r y existing building(s). Demolition permit is required prior to issuance of buildings x� rE< ? �' F a' p a. `Tw.�^ .FS,. `.._ c!.L�+c a',� i' fir ay. permit for new building. ❑s EAPRESS+ r -s 7 ❑ PLAnNPVGPLAN REEF Ewst� ED _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure � � ZsTANDARn+, C3 PVBLIewoRKS Cox y form if any Hazardous Materials are being used as part of this project. x3 LARGFjjs �' ykSECI � FIREDEPT� dtfd � r a { a a _Copy of Plannino Appro�al Letter or Meetino with Plannino prior to ❑,�11fAJOR F ' ❑ SATIT4RY SER DISTRICT d submittal of Building Permit application. ER �a � f f 4 1a� tk 7i4 rz T 1 a r Aay�°- - � . _z. _av3 _.i � ❑.EN�.IROI�T4ENtA IrEAETH ,,R _§ BldgApp_2011.doc revised 06/21/11 cCRT Y OF cCUP ElEgTRNO FEE IESTRMATOR— BUR LDRIYO DRVISION ADDRESS: 19929 STEVENS CREEK BLVD /DATE: 05/22/2014 REVIEWED BY: MELISSA APN: 36905039.19929 BP#: *VALUATION: $20,000 "'PERMIT TYPE: Building Permit PIAN CIIECK TYPE: Tenant Improvement PRIMARY PENTANIATION USE: Commercial Building PERMIT TYPE: 1B TIS WORD ICEBOX T.I. TO RECONFIGURE E RESTAURANT 200 S.F. SCOPE OCCUPANCY TYPE: TYPE OF FIR AREA PC FEES PC FEE IID BP FEES BP FEE IID CONSTR. s.f. B (Tenant Improvements) II-B,111-B,IV,V-B 200 $2,036.00 IBTIPLNCK $571.00 IBTIINSP TOTALS: 200 $2,036.00 $571.00 MEC]H[,HOURLY 0 Yes D No PLUMB,HOURLY ® Yes Q No E]LEC,HOURLY ® Yes C)No Ilcc,i `Iwi,l77e(", 11111irh- P"oir Ch''C;i Llec.Plan Check nc")'m i i e' 1'h,,nh 1'crmii I,ee /iec I'Vo cif Fee. E17- Plumb h7'sp =1� Other I,lec /fzsp. Lj c" 1'1,:u b' l p. Vre ]Jec. Insp.Fee: NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These fees are based on the prelimina information available and are onl an estimate. Contact the De t or addn'l in o. FEE ITEMS (Fee Resolution 11-033 Eff.7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,036.00 Select a Misc Bldg/Structure Suppl. PC Fee: E) Reg. ® OT Eflhrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $571.00 Suppl. Insp. Feer Reg. ® OT 1Qil hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 El Work Without Permit? ® Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential E) Building or Structure d Strong Motion Fee: IBSEISMICO $4.20 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 1 $2,612.20 $0.00 TOTAL FEE: $2,612.20 Revised: 04/01/2014