11060072 (2) i
CITY OF CUPERTINO BUILDING PERMIT
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BUILDING ADDRESS: 19060 STEVENS CREEK BLVD CONTRACTOR:SMI CONSTRUCTION INC PERMIT NO: 11060072
OWNER'S NAME: UNITED POLARIS INC 595 MONTAGUE AVE DATE ISSUED:08/15/2011
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OWNER'S PHONE: 4082553999 SAN LEANDRO,CA 94577 PHONE NO:(510)351-3288
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❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB �I
License Class Lic.#
p _ MECH m RESIDENTIAL COMMERCIAL µw
Contractor Date �J
I hereby affirm that I am licensed under the provisions Chap er 9 JOB DESCRIPTION:MICHELLE'S PANCAKE HOUSE-COMMERCIAL TENANT
(commencing with Section 7000)of Division 3 of the B iness&Professions TYPE
I HOOD,
RESTROOM,
,RESTAURANT SPACE INCLUDES
Code and that my license is in full force and effect. TYPE 1 HOOD,RESTROOM,SERVICE CENTER KITCHEN,
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
performance of the work for which this permit is issued.
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 Sq.Ft Floor Area: Valuation:$120000
permit is issued.
APPLICANT CERTIFICATION APN Number:37507046.19060 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the ity of Cupertino against liabilities,judgments,
costs,and expenses which in accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Add'tonally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source r la S peer the Cupertino.Municipal Code Section
9.18.
Issued by:< G� Date:
Signature .� Date ^'— -
❑ O#NER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)sho dd I store or handle hazardous material.
Additionally,should I use equi ent or devices which emit hazardous air
permit is issued. contaminants as defined by t Bay Area Air Quality Management Dish•ict I.will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code Sec o 5,25533,and 25534.
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 Owner or author' a nt: {
forthwith comply with such provisions or this permit shall be deemed revoked. / ate:
APPLICANT CERTIFICATION /CONSTRUCTION LENDIN AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of nwrk's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(See.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
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 ARCHITECT'S DECLARATION
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CONSTRUCTION PERMIT APPLICATIOW
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
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---- - - (408) 777-3228 FAX(408) 777-3333• building(d),cupertino.org
C1 RTINQ
❑NEW CONSTRUCTION [:1LJ ADDITION' ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADD
C' APN
OWNERNAME - PHONFy E-MAIL
STREET ADDRESSCITY, STA FAX
t0 is ILA
CONTACT NAKaVn PHONE E-MAIL
J Cd
$TREETAD RES$ CITY TATE, FAX
F1 tt
❑ OwNER ❑ OWNER-B ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT E ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMB LICENSE TYPE BUS.LIC#
COMPANYNAME 1� E-MAIL FAX
STREE DRESS CITY ATE,Z PHONE y
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORKIV
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EXISTING USE PROPOSED USE CONSTR.TYPE #STORIE FFI
AL 'TI
EXISTGDTl ORT� DEMO TOTAL
AREA AREA J Cd AREA NET AREA
BATHROOM KITCHEN OTHER z 4ar4
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑ DETACH
❑ ATTACH
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#DWELLINGUNITS: IS A SECOND UNTr ❑YES SECONDSTORY ❑YES ! sF -
BEING ADDED? ❑NO ADDITION? ❑NO
PRE-APPLICATTON ❑ YES IF YES,PROVIDE COPY OFPLANNER'S NAME: RECEIVEtr$I'' T AT,. AtitT.�4.TION �
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER
By my signature below,I certify to each of the foilI m the property owner or authorized agent to act on the property owner's beh f. I have read this
application and the information I have provided i corr t. I ave 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 iructio . I r7ze representatives of Cupertino to enter the above-i dntifie pro�rperly for inspection purposes.
Signature of Applicant/Agent: Date: f
SUPPLEMENTAL INF RMATION REQUIRED
New SFD or Multifamily dwellin s: Apply for demolition permit for CL overt"taloo3tlxrl x �-~ "" �
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. i � rAraNuvrirrvr>sw'
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Cf sTArt3 A> CI.rtrsY[Ptvoxss
form if any Hazardous Materials are being used as part of this project. o
Copy of Planning Approval Letter or Meeting with Planning prior to
— �M9.Iox � �AAx�.SEw><xDls��r
submittal of Building Permit application.
C1= v R''"NTA
BldgApp 2011.doc revised 03/16111
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Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERT iNO
Fax: 408-777-3333
CONTRACTOR SUBCONTRACTOR LIST
JOB ADDRESS: Abil PERMIT#
OWNER'S NAME: PHONE# —
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE:
''Our municipai code requires 1 businesses worki in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUP C SPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUB O T ACTORS 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
2f
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C�
Ow er/Contactor Signature Date
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August 1, 2011
City of Cupertino
Building Department
10300 Torre Avenue
Cupertino, CA 95014-3255
Subject: Michelle's Pancake House @ 19060 Stevens Creek Blvd.,Unit 107A,
Cupertino, CA 95014
To Whom It May Concern:
Please be advised that the proposed building as referenced above will not have any
adverse impact on the City of Sunnyvale's sewer system.
An additional sewer impact fee of$1,502.75 has been paid to the City of Sunnyvale. This
additional sewer impact fee is a result of change of use from a market to a restaurant.
Please call me if you have any questions at(408) 730-7636.
Very truly yours,
Mark Rogge
Assistant Director of Public Works/City Engineer
Bennett Chun, P.E.
Civil Engineer
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County of Santa Claw Go u�
T�
Department of Environmental Health
1555 Berger Drive, Suite 300
San Jose, California 95112-2716 } € \
(408)918-34001850 ¢�
www.EHinfo.org b STA CLQ
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�:.
July 1, 2011
Michelle's Pancake House PROJECT NUMBER: SR0836880
Attention: Eric Chang PROJECT NAME: MICHELLE'S PANCAKE HOUSE
10410 Flora Vista Av PROJECT ADDRESS: 19060 STEVENS CREEK BLVD
Cupertino, CA 95014 CUPERTINO
Dear Mr. Chang:
Drawings for the above project have been reviewed and approved by this department. This approval
shall expire by limitation and will become null and void if the construction, reconstruction, alteration,
or other work authorized by this approval is not commenced within 180 days from the date of
approval. Please notify this office when construction begins.
Please retain one copy of the approved drawings on the job site. A FOO® FACILITY
CONSTRUCTION CARO has been attached to the job copy and must be posted with the other
building permits. Present at least two (2) copies of the drawings to your local building official for the
required permit application and approval. Any change to the drawings as a result of reviews
by Other jurisdictions must be brought to the attention of this department as soon as
possible to avoid construction delays.
Please be advised that you are responsible to contact this office to arrange for a construction
inspection before rough plumbing signoff, installation of equipment, and again upon completion of
the project.
Absolutely no food storage or food preparation will be allowed onsite until the department issues a
Permit to Operate. This permit will be issued upon the successful conclusion of our final construction
inspection. You will also be asked to submit performance test of the mechanical exhaust
system, if one is present, and verif%cation of garbage collection before the issuance of
the Permit to Operate.
This food establishment will be required to have either the owner or an employee successfully pass
an approved and accredited food safety certification examination. This certification must be obtained j
within sixty (60) days after your Permit to Operate is obtained. Contact this department for more
information.
If you have any further questions or would like to call for an inspection appointment, please contact
the Department at (408) 918-3400, between 8:00 a.m. and 5:00 p.m., Monday through Friday.
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ny truly yours,
Can Van Thai, RE S
Senior Environmental Health Specialist
Plan Review and Construction Unit
cc: City.of Cupertino Building Department
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Board of Supervisors: Mike\Vasserman, George Shiraka\va, Dave Cortese, i\,en Yeager, Liz Kniss
County Executive:Jeffrey V. Smith e I
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 19060 stvns crk blvd. DATE: 06/09/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: 1$120,000
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*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION 1 B TI
USE: PERMIT TYPE:
WORK U. commercial restaurants ace includes type I hood restroom service center, kitchen new
SCOPE equipment.
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
B (Tenant Improvements) II-B,111-B,IV,V-B 1,950 $1,976.00 IBTIPLNCK $1,601.45 IBTIINSP
TOTALS: 1,950 1 $1,976.00 1 1 $1,601.45
MECH,FIOURLY 0 Yes' E) No PLUMB,HOURLY 0 Yes 0 No ELEC,HOURLY 0 Yes Q No
'!
Fee:
i c:e
F.) ..�� �1 3
ijl'i'�-. ., ts�,
El
NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l in o.
FEE ITEMS (f ee Resolution 09-051 Elf. 7,i1/10,) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $1,976.00 Select a Misc Bldg/Structure
Suppl.PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $1,601.45
Suppl.Insp.Feer Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Acoustical Fee: 0 Yes 0 No $0.00 0
Work Without Permit? 0 Yes Q No $0.00 0
Planninu Fee: $0.00 Select a Non-Residential 0
Building or Structure 0
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Strong Motion Fee: IBSEISMICo $25.20 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $5.001 1 +
SUBTOTALS: $3,607.65 $0.00 TOTAL FEE:' $3,607.65
Revised: 04/29/2011