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14120042CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20803 STEVENS CREEK BLVD
CONTRACT(' /
PERMIT NO: 14120042
l� eU
OWNER'S NAME: SAICH WAY STATION LLC
DATE ISSUED: 03/23/2015
OWNER'S PHONE: 4157175870
PHONE NO:
• LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL Q COMMERCIAL
RESTAURANT TENANT IMPROVEMENT (THE MELT) (1468
License Class_ Lic. # +"
SQ
/
I,/- 2
FT).
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
Sq. Ft Floor Area:
Valuation: $420000
performance of the work for which this permit is issued.
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: 32632042.00
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
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 DAYS CALLED INSPECTI N.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
f /
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Date:
with all non -point source regulations per th Cupertino Municipal Code, Section
9.18.
/
RE- ROOFS:
Signature / Date A6k�/S__
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
❑ OWNER- DECLARATION
inspection.
BUILDER
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
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. I 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 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
Section 3700 of the Labor Code, for the performance of the work for which this
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: Date: /
permit is issued.
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
CON RUCTION 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
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20803 STEVENS CREEK BLVD CONTRACTOR: K R CONSTRUCTION PERMIT NO: 14120042
OWNER'S NAME: SAICH WAY STATION LLC
OWNER'S PHONE: 4157175870
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #_ j
Contractor / : g, Date r_
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
of the work for which this permit is issued.
I h ve 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.
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 regulationer the Cupertino Municipal Code, Secti
9.18.
4110 W PEWAY DR I DATE ISSUED: 03/23/2015
LAS VEGAS, NV 89118 1 PHONE NO: (702) 891 -0479
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
STE 110 -THE MELT RESTAURANT TENANT
IMPROVEMENT (1468 SQ FT).
REV # 1 - REVISE PATIO GAS LINES & BATHROOM DOOR
SS ANALYSIS- ISSUED 5/11/15
Sq. Ft Floor Area: I Valuation: $420000
APN Number: 32632042.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAY.S4190_'Mzh LED INSPECTION.
RE- ROOFS:
Signature Date '''- All roofs shall be insp ed 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.
❑ ER- 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).
I hereby affirm under penalty of perjury one of the following three
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
permit is issued.
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.
Date
Signature of Applicant: Date:
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(x) 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, Section , 25 ,, an 25534.
Owner or authorized agent: — Date: it
CON RUCTION 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
174
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
CUPERTINO (408) 777 -3228 • FAX (408) 777 -3333 • building Qcupertino.orq
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT 4
PROJECT ADDRESS r r. ��. 1 „ / � APN #
(�
OWNERNAME L C (.t W f-jv PHONE E -MAIL
-5ii-
STREET ADDRESS CITY, STATE, ZIP FAX
��
ifG1- cA�►?— F C, C,O
CONTACT NAME PHOMP- — E -MAIL
'TWtC� C21 6aU_EMo9-6 0 Z ©S Otto °mill tL FIST -}S;)L gtc - co M
STREET ADDRESS CITY, STATE, ZIP FAX
T 4 n.— s,1 C_ tL ' c 6 Cam- 5 L d�+
❑ OWNER ❑ OWNER- BUILDER 0111RAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LTC k
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECTIENGINEER NAME
LICENSE NUMBER
Zs-�>o
BUS. LIC #
'WIC-$ &P,
COMPANY NAME
E -MAIL
FAX
SF-4 SI
L_
-T-W 51aS1 �G F
�1
STREET ADDRESS
CITY, STATE, ZIP C_
PHONE
TS NAM k S
SA FRAa�tc c o aP-
S 1 o 2-0s, 315 0
DESCRIPTION OF WORK
,.IT T!RQ 1 L, 0 T O>,= TP YL-A �1-t- " H o E
'E ISTIIJ(? sly- COr� ST12Ur✓TTU �. i tJ S �� �
adiG.
EXISTING USE
PROPOSED USE CONS'[
& TYPE # STORIES
/� _ Z
,
V
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
AREA I i I r
F
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NEr AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA ,^
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA DETACH
❑ ATTACH
K DWELLING UNITS:
IS A SECOND UNIT ID YES
SECONDSTORY ❑YES
BEING ADDED? ❑NO
ADDITION? []NO
PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
C y , {` „,rr „:
TOTAL VALUATION:
PLANNING APPL ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
e
By my signature below, I certify to each of the following: I am the property owner or authoriz age o on the erty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work a rate. 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 purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFO ?ATI N REQUIRED
PANCkAECJGTYPE
New SFD or Multifamily dwellings: Apply for demolition permit for
°
' t
❑ ' T`k`
ri
existing building(s). Demolition permit is required prior to issuance of building
OVER TAE COUNTER `' �,
BUILDING PLAjy RE{ ]E41 j t, x
for new building
kiss�w
ANnrrG PLAN REVLEw k
permit
��
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
"%V1 s :'❑
PUBLIC WORKS" ?_ I
form if any Hazardous Materials are being used as part of this project.
- r
,
❑
LARGE` n'�
, FJRE DEPT 1 Q
Copy of Planning Approval Letter or Meeting with Planning prior to
t < 4 Fr
x t
ti'�.ci i tct s.`
s
_
0 MAJOR
❑SANITARYSE�VERDISTRICT'
submittal of Building Permit application.
rs_..�..:,.,,. ,�,.'r�.. ,.�c,.� - ->
��s1 .ENVIRON➢'iENTAY��jEALTAWSy''I' ,.
BldgApp_2011.doc revised 06121111
CUPERTINO
❑ NEW CONSTRUCTION
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIO®RIGINAILPERMIT 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 - 3228.- FAX (408) 777 -3333 • buildingP- cupertino.org
❑ ADDITION ❑ ALTERATION / TI VISIO DEFERRE 9 O O y2
PROJECT ADDRESS
fry,. roc 5�•�
OWNERNAME
A E -MAIL
PHONE 2j
'
STREET ADDRESS CITY, STATE ,ZIP
R
FAX
L C
CONTACT NAME [ -W '03 ���� `
/Q d
PHO/a ' �r �6
E -MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
era
OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E -MAIL
r
•
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
Y
ARCHITECT/ENGINEERNAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK ,
�•
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE
TYPE
OCC,
SQ.FT,
VALUATION (S)
EXLSTG
NEW FLOOR,
.DEMO
TOTAL
AREA
AREA
AREA
NET AREA
-.
BATHROOM.
KITCHEN.
OTHER.
.
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: LJ DETACH
❑ ATTACH
# WATLLINGUNITS:
IS A SECOND UNIT ❑YES
SECOND STORY ❑YES
BEINGADDED? NO
ADDITION? E]NO
.
PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
CEI Y'
'*
�
TAL VALUATION:
PLANNING APPL,- El ' PLANNING APPROVAL LETTER
EICHLER HOME? E3 NO
-
la
�
- ,� ".-
By my signature below, I certify to each of the following: I am the property owner or authonzed agent to on the 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 verify ' curate. I agree to comply with all applicable local
ordinances and state laws relating to b construe ' I aut a representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent:
Date:
SUPPLEMENTA ZATION REQUIRED
j�
w
_ ,,,PL:ANCHE,GK?'1P,E �__.,,
New SFD or Multifamily cl �Rings: Apply for demolition permit for
�4 �
� a
existing building(s). Demolition permit is required prior to issuance of building
OV- ERTHi<COUhTER ,
BUII,`DILVGPL�INREVIEFi'
permit for new building.
=fit ExPxss ��
f 4
RLANi\INGP ANREYLEW
��� •�� s'
_ Commercial. Bldgs: Provide a completed Hazardous Materials Disclosure
©TANDARD ,
Q4 uBLIwoRlcs�
form if any Hazardous Materials are being used as part of this project.
LARGE ;
LFIItEDEPTE
Copy of Planning Approval Letter or Meeting with Planning prior to
I x
x
_
submittal of Building Permit application.
© MA7oR t r
�AI�TfAR7�SEiYEFtDISTRICT
4
Bld,-App_201 1. doc revised 06121111
FM-1 CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preffiflWdna in ormation available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Fee Resolution 11 -053 f f. 711113)
ADDRESS: 20803 STEVENS CREEK BLVD
DATE: 05/11/2015
REVIEWED BY: MELISSA
Fiblech. Perrnit Fee:
APN: 326 32 042
BP #: 14120099
*VALUATION:
Iso
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY
USE: Commercial Building
Civil / Religious activities
in BQ zone? 0 Yes (E) No
PENTAMATION
PERMIT TYPE: 1 GENCOM
WORK
REV # 1 - REVISE PA -1 -10 GAS LINES & BATHROOM DOOR /EGRESS ANALYSIS - ISSUED 5/11/15
SCOPE
0.0
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preffiflWdna in ormation available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Fee Resolution 11 -053 f f. 711113)
Nfech, Plan Check
Phuub. Plan Check FT
Elec. Plan Checic
Fiblech. Perrnit Fee:
Plumb. Permit I ee:
Elec. Permit Fee: .
Other it /ech. Irasp•
Other Plumb Insp.
Other Llec. Insp. Ll
;ldech. Insp. Fee:
Phtmb. Insp. Fee:
Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preffiflWdna in ormation available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Fee Resolution 11 -053 f f. 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes Q No
$0.00
0 hours Plan Check, Hourly
$143.00 ISTPLNCK
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee-0 Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTAXC
$0.00
Administrative Fee:
Q
G
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning-Fee.
$0.00
Select a Non - Residential E)
Building or Structure 0
i
Travel Doeumenlation Fees:
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:`=
$0.00
$143.00 µ ° TOTAL FEE :
$143.00
Revised: 04/01/2015
FM-7 CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
19
ADDRESS: 20803 STEVENS CREEK BLVD
DATE: 12/08/2014
REVIEWED BY: MELISSA
PC FEE ID
APN: 326 32 042
BP #: �--
*VALUATION: 1$420,000
xPERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE:
IATIPLNCK
PENTAMATION 1A TI
PERMIT TYPE:
WORK
'THE MELT'- T.I. TO BUILD OUT SHELL TO CREATE N RESTAURANT (1,468 S.F.
SCOPE
PME Plan Check:
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
A (Tenant Improvements)
II- B,III- B,IV,V -B
1,468
$2,473.70
IATIPLNCK
$1,005.50
]ATIINSP
l..�Jec.'. Insp. Fee:
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,005.50
Suppl. Insp. Fee: (j) Reg. Q
OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
TOTALS:
1,468
$2,473.70
$0.00
$1,005.50
MECIi, . HOURLY .Yes No
'PLUMB, HOURLY Q Yes No
ELEC, HOURLY Q Yes Q No
Hech. flan Cheek
Plumb. Plan Check
Checlf
:bIPCh. Perillil Fee:
PllAmb. Pi: rmlt Fe
l;li?L'. Permit l`C'3:
Other A/ech. Trim
Q(her Plumb Imp,
Orhe!• L'lec. InSg7,
;1.lech. hzsp. Fee:
Phtwb. hlsp, ree:
l..�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 Dreliminarv, information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11 -053 E . 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,473.70
Select a Misc Bldg/Structure
or Element of a Building
i
Suppl. PC Fee: ) Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,005.50
Suppl. Insp. Fee: (j) Reg. Q
OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax:
T7_
Adin;nistrative Fee:
Q
Work Without Permit? 0 Yes ) No
$0.00)
Advanced Planmin& Fee:
$0.00
Select a Non - Residential
Building or Structure
i
Trm,,el Docuinenlation Fees:
Strong; Motion Fee:
IBSEISMICO
$117.60
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$17.00
SUBTOTALS:
$3,613.80
$0.00
TOTAL YEE:
1 $3,613.80
Revised: 10/01/2014
CUPERTINO
TEMPORARY CERTIFICATE OF OCCUPANCY FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B:O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 950143255
(408) 777 -3228 • FAX (408) 777 -3333 • build ingacupertino.org
API 3 O Y Z
BP #:� Y�Z
Z
DATE:
LEVEL
PROJECT $
-3rv�l
Z
,JYtry
5
`
❑ APPROVED WITH CONDITIONS"
SITE
ADDRESS:
El APPROVED WITH CONDITIONS -
OWNER'S NAME:
7FAX#:
PHONE #:
/% /.j^`� %/? • .570
MAILING ADDRESS (if diffeY6nt from site address):
S J
/U
CONTRjCTQR: / /
!�• l� �rtS 1f'dvT78M
PHONE
FAX #:
CONTACT: 0
G¢ ✓I /1 v !J �Gr d�1 p(,sf r
PHONE #:
FAX #:
�c�l ' `1-7 i
TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION
BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION (BLDBONDS] CODE
�v EDITION:
CHECK ❑CASH BOND OF BOND: 5K min-10K max) "
TCO EXPIRATION FEE: 286.00/mo TOTAL FEE: $
DATE (6 MONTHS MAX): tIt Zg�j [1T.EMP000]
USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
-3rv�l
Z
,JYtry
5
❑ APPROVED
. .... 6.
❑ APPROVED WITH CONDITIONS"
r!t er:
igriature :.......................... ............................... Date:...................... CI APPROVED
El APPROVED WITH CONDITIONS -
OTHER DEPARTMENT / AO NCY APPROVALS:
Planning
�Iz
/APPROVED
❑ APPROVED WITH CONDITIONS"
Signature
.: .:.
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Signature:
Date: q❑ APPROVED
❑ APPROVED WITH CONDITIONS*
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Signature
❑ APPROVED
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❑ APPROVED WITH CONDITIONS"
r!t er:
igriature :.......................... ............................... Date:...................... CI APPROVED
El APPROVED WITH CONDITIONS -
*CONDITIONS OF COMPLETION - Attach a letter signed by the contractor and owner of the property
stating the list of items required to be completed for each individual Department before final occupancy
can be granted. Include approximate completion dates for each item.
The undersigned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or
buildings complete and in compliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration
date specified. If this Temporary Certificate of Occupancy expires, the total amount of the bond may be forfeited and the non - compliance
ma result in gpenforcement action.
Owner JJ' Contractor /
Sianature%/....l _ ....... Date :........................ Signature: . .._1, .... ................. Date:.PZA1.1-
IThis temporary certificate ensures that all fire protection and life safety systems havop"n completed, inspected, successfully tested and I
approved for the specific area of the building specified above to provide a reasonable degree of safety to the occupants from fire and
similar emergencies.
Building Official./ ............................ ... ..... Print :.................:4 -..... .. .......:. :.........Date:......
DEPARTMENT ACTION: After determination, copies to: 1) applicant, 2) permit file
TempOccForm_2011 doc revised 717114
Building. Department
City Of Cupertino
10300 Torre Avenue
Cupertino, .CA 95014 -3255
Telephone: 408- 777 -3228
C U P E RT I N O Fax: 408- 777 =3333
CONTRACTOR / SUBCON TRACTOR LIST
JOB ADDRESS: "
S� ���
PERMIT # O U
OWNER'S NAME:
Alf
PHONE # "
GENERAL CONTRACTOR:
2 . Ca „. �•o ..
BUSINESS LICENSE #
ADDRESS: y ' �•
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CITY /ZIPCODE:
*Our "munieipal code requires all b sinesses working in the city,to have a City of Cupertino business license.."
NO BUILDING- FINAL; OR FINAL OCCUPANCY INSPECTION(S) WILL BE. SCHEDLTLED_"UNTIL THE
GENERAL CONTRACTOR AND ALL .SUBCONTRACTORS HAVE OBTAINED A CITTY 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 P 30 Z',S's
i/ Electrical G Ste . r
Excavation
Fencing
Owner / Contractor Signature Date ”
Flooring/ "Carpeting
Linoleum / Wood "lca..
�d/ �w.t
Glass / Glazing
V,Heat'ing
Insulation...
-
Landscaping
Lathing
Masonry
✓
Painting / Wallpapers
Paving
Plastering
Plumbing
Roofing
Septic Tank. .
Sheet Metal -
Sheet Rock
;
Tile
Owner / Contractor Signature Date ”
CUPERTINO
TEMPORARY CERTIFICATE OF OCCUPANCY FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildingn.cupertino.org
1i ,
AP
BP # :
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DATE:
OCC
LOAD
VALLUAT� ION:
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❑ APPROVED ITH CONDITONS*c
SITE /
ADDRESS: � D � 1`CVs !r
`
OWNER'S NAME:
Tom`
PHONE #:
FAX #:
y /S�- 71'7-.:57_g7,6
MAILING ADDRESS (if diffe-'r6nt from site address):
.. ........... ........................ e:...............
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CONTRACTOR:
/G /� �r
PHONE #:
FAX #:
�c3� /- mil% 'f - el 5 3
CONTACT: / 0
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PHONE #:
FAX #:
ILS-1 - ?7— $ 4 3
. vI!nHOGCr
TFMPr)PARY CERTIFICATE OF OCCUPANCY INFORMATION
BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION BLDBONDS CODE
Dd CHECK El CASH BOND OF BOND: 5K min -10K max $ l ��U EDITION:
TAO EXPIRATION FEE: $286.00/1710 TOTAL FEE: $ Z�b °= [1TEMPOCC]
DATE (6 MONTHS MAX): "/ l
USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
Date:.......
14 Z_
❑ APPROVED
❑ APPROVED ITH CONDITONS*c
Signature :....... ...
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APPROVED
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anning
Si nature:..,.. ,�.:......
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APPROVED
❑APPROVED WITH CONDITIONS*
Fire
Date:.......
❑ APPROVED
❑ APPROVED ITH CONDITONS*c
Signature :....... ...
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VED ITH CONDITIONS*
Signature:.. ....
.. ........... ........................ e:...............
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ter:
APPROVED
APPROVED WITH CONDITIONS*
Signature: ..... ....................................................
Date:......................
*CONDITIONS OF COMPLETION - Attach a letter signed by the contractor and owner of the property
stating the list of items required to be completed for each individual Department before final occupancy
can be granted. Include approximate completion dates for each item.
The undersigned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or
buildings complete and in compliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration
date specified. If this Temporary Certificate of Occupancy expires, the total amount of the bond may be forfeited and the non - compliance
may result in forcement action.
Owner Contractor
Signature:....
This temporary certificate ensures that all fire protection and life safety systems hawb e completed, inspected, successfully tested and
approved for the specific area of the building specified above to provide a reasonable degree of safety to the occupants from fire and
similar emergencies.
Building Official: _; -: ...............: %'..s - '...Print:....... <-�.�? �......... ..0 %: Z. ........ Date: ........
C�.-....:..-.:!
DEPARTMENT ACTION: After determination, copies to: 1) applicant, 2) permit file
TempOccForm_2013.doc revised 717114
