B-2017-1353CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1353
10101 N DE ANZA BLVD CUPERTINO, CA 95014 (326 34 071) HOLDER
CONSTRUCTION
GROUP LLC
ATLANTA, GA 30339
OWNER'S NAME: WATERDRAGON 289 LLC
DATE ISSUED: 08/15/2017
OWNER'S PHONE: 408-783-2338 I I PHONE NO: (770) 988-3289
License Class B Lic. #977983
Contractor HOLDER CONSTRUCTION GROUP LLC Date 10/31/2018
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:
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
L" Section 3700 of the Labor Code, for the performance of the work for which this
1 permit is issued.
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
and state laws relating to building construction, and hereby authorize
representatives of this city to: enter upon the above mentioned property for
inspection purposes. 0e) agree to save 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 with all non -point
source regulations per the Cupertino Municipal ode, Section 9.18.
Signatur Date 08-15-2017
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: ,
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 construct the project (Sec.7044, Business & Professions Code).
hereby affirm under penalty of perjury one of the following three declarations:
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.
2. I 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
permit is issued.
3. 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 become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
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 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, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Signature Date 08-15-2017
PERMIT INFO:
BLDG —ELECT _ PLUMB
MECH _ RESIDENTIAL X COMMERCIAL
JOB DESCRIPTION:
APPLE T.I. PREP - (11,452 SF) FOR B-2017-1015
Sq. Ft Floor Area: Valuation: $2800000.00 ,
APN Number: Occupancy Type:
326 34 071 1 A (Tenant Improvements)
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Kim Dunbar
Date: 08/15/2017
RE -ROOFS:
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.
Signature ofApplicant:
Date: 08-15-2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 255,U.
Owner or authorized agen
Date: 08-15-2017
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 A
(408) 777-3228 * building@cupertino.org PEMIT #B -ZpC
CUPERTINO
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION MrT.I. ❑ MEP ❑ RE -ROOF ❑ SWIMMING POOL/SPA
PROJECT ADDRESS /0/,/ q �✓ ^, W', }v� APN # 3,2 J/ y S 2 Q
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OWNER NAME PH/ONE
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E-MAIL
STREET ADDRES I
CITY, STATE, ZIP / `'
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CONTRA OR NAME ❑ OWNER -BUILDER
COMPANY NAME
LICENSE NUMBER
LICENSE TYPE
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STREET ADDRESS
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❑ ARCHITECT ❑ OWNER ❑ OWNER AGENT ❑ CONTRACTOR AGENT El ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP PHONE
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DECRII'TON L (��!^�1.7 1 ', Y C/ D .1— / l�� a. _ �l D4
❑SINGLE-FAMILY/DUPLEX ❑ MULTI -FAMILY ❑ INDUSTRIAL [9 OMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION ($)
EXISTING USE
EXISTING SF
NEW FLOOR SF
PORCH
SF DECK SF
DEMO SF
STORIES #
TOTAL NET SF
I
I
REMODEL
REMODEL KITCHEN
REMODEL OTHR GARAGE
❑ ATTACHED
J
BATHROOM SF
SF
SF SF
❑ DETACHED
EXISING vj/FES
FIRE SPRINKLERS ❑ NO
S
EICHLER YES
O
SECOND STORY ADDITION 0 YE
0
DWELLING SECOND DWELLING ❑ YES ❑ ATTACHED ❑ DETACHED OTHER
UNITS # UNIT ADDITON: ❑ NO S F
POOLS ❑ FIBERGLASS ❑ VINYL -LINED ❑ GUNITE ❑ PREFABRICATED
14
POOL - SF SPA - SF SPA ATTACHED ❑ YES ❑ NO I TOTAL - SF
RECE E
TOT41, VALUATION:
Commercial or Multi -Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval
Y✓1
RE -ROOF
EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑
WOOD SHINGLES ❑ TILE OTHER (SPECIFY) '
REMOVE /REPLACE ❑ NOI
IF NO
PLYWOOD ❑'h" ❑ 3/8"
PLYWOOD TYPE:
PITCH:
ROOF CLASS
F] YES
# OF LAYERS
THICKNESS ❑ 5/8" OTHER
I ❑ OSB ❑ CDX OTHER
—:12
A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER
*Provide a signed copy of the Cupertino's Tear -Off Policy SF #of SQUARES
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
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 poses. I a oge and authorize all information containe on this application form
to be made available for public record.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUI D
*New SFD/Second Dwelling Units/Multifamily 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 Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA -Provide a letter of approval from the Home Owner's Association
94t,
BldgApp_2017.doc revised 08/01/17
AWID I a
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11111111Fillm TESTING INS;
G�N� �� INC. 11-30,10
Date: G I 7 DSA File#• DS' fiti
A .#-
PP.
Project#• AI e OSHPD#•
Project Name: A PP f Permit/SF App.#• B-- 4/ 7 - 1 3 5 1
Address: f a 101 De. ftrilzdf P tc / Tow Code: / ,
City: C G P er•`1 r 0 Start Time: 7,t0
Requested by „,,Ve ji( Hours: L :
Reported to: D AN et+1 of(Company Name): Wo/o [
Proof Load Testing Report(150)
Applied a❑tension proof or torque load of 1 0 ❑lbs.or L 1.-lbs,
to (size)diameter k (3't t4-s I (-k (brand) ❑epoxied dowels ❑ epoxied Allthread anchors
rig expansion ancho ❑ powder actuated pins ❑ other
Located m thefloor ❑ wall ❑ ceiling ❑ other at I I-Ve. &7f N0 -`- W (location)
for -rt.,ice._ ..e- t c.®i,, �
t
(No.)anchors/dowels of a total of L installed were tested representing /00 percent
Er without visually apparent distress or failure.
❑ (No.)anchors/dowels failed to meet proof load requirements.
Identified and reported failing anchors/dowels to at the jobsite for appropriate action.
Applied a❑tension proof or 'torque load of 1100 ❑lbs.or aft.-lbs,
to t f (size)diameter o 7- t 0 7' (brand) ID epoxied dowels 1=1 epoxied Allthread anchors
expansion anchors ❑ powder actua0d pins ❑ other:
Located in the ❑ floor ❑ wall ceiling ❑ other at L(We IT leo e yr (location)
for
/ Li (No.) anchors/dowels of a total of installed were tested representing /CO percent
II without visually apparent distress or failure.
❑ (No.)anchors/dowels failed to meet proof load requirements.
Identified and reported failing anchors/dowels to at the jobsite for appropriate action.
Proof loading values and rate of testing were supplied by ❑ Drawings No(s)
Other WV Mti e 7 i U1e B &(
❑ Final acceptance is pending written approval or corrective action as noted. ❑See attached RFI.
❑ All non-compliance items were brought to the attention of at the job site.
Note:
❑Showup;❑Stand-by time;❑Job Cancelled;❑Re-inspection;Hours:
The work u was❑ as not inspected in accordance with the Bui ng Department or 1:1 DSA or 0 OSHPD approved documents.
The work inspected mIJet❑did not meet the requirements of the Di Building Department or 0 DSA or ❑ OSHPD approved documents,
❑except as noted above.
Drawings II lir% Dated ` 1 - (7 0 City 0 County ❑DSA 0 Shop
Inspector 177,/ r ------, ertification# /0 71C - Date: /in -/ I
Received by- t C CI/-7`, M/1f4-1/ �'/ - /71; ''01 P r Date:
e
Corporate Office-2811 Teagarden Street-San Leandro,California 94577-(510)835-3142-FAX(510)834-3777
www.Testinq-Enqineers.com
MINI -
Li ,_
TESTING_NGINE RS, INC. 1 ,
7
jj
Date: /0 -13 ' 7 DSA File#: D A-
t i.#:
Project No.: e- 4 OSHPD No.: ''''----
ProjectProject Name: p Permit/SF App.#: p.-20/ 7- 13c 3
Address: o/ / Nr' ' et, Tow Code: /
City: C u p e r Start Time: 40
Requested by: Nim/ Hours:
Reported to: i 4,firk A I of: 'Aye./foe,c
❑ EPDXIED DOWELS - 125 10° EPDXIED ANCHORS 126 ❑ EXPANSION ANCHORS - 127
❑Witnessed the drilling of holes of proper diameter and depth.
Inspected predrilled holes for proper diameter and depth. Expiration Date of Epoxy 17—18'
❑'Observed the cleaning of holes and the injection of iiiiiii 200 epoxy.
or
the insertion of epoxy capsules.
Witnessed the proper insertion of:
V
Qty. Bar#1 Type Length, Embed. Location
Dia,in. in. in.
. 4fo cdtas ` z,/ .
e 40} ' &? elf e ? ii i le
o o f sie �, 7,/.,-)147,/.,-)14. � /./, " i
Remarks!:
Notes: ❑ Type ❑ Do not type
The work was❑ as not inspected in accordance with the[Buil" ' g Department or CIDSA or 1:1OSHPD approved documents.
The work inspected met❑did not meet the requirements of the Building Department or❑DSA or 1=1 OSHPD approved documents,
except as noted above.
Material sampling❑was❑was not❑N/A performed in accordance with the Building Department or DSA or OSHPD approved
Documents
Drawings gPDated �- � � ✓ ❑City 1=1 County El Shop
_� 7 -/5—/
Inspector: e _ , Certification# Date:
'-
Received by: I car; , f /este: _--
a
Corporate Office-2811 Teagarden Street-San Leandro,California 94577-(510)835-3142-FAX(510)834-3777
www.Testinq-Enqineers.com