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B-2016-2456CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2456 19459 STEVENS CREEK BLVD STE 110 CUPERTINO, CA 95014 (316 20 112) J T CONSTRUCTION SERVICES INC SAN JOSE, CA 95112 OWNER'S NAME: MAIN STREET CUPERTINO AGGREGATOR LLC OWNER'S PHONE: 408-996-9886 LICENSED ONT A TOR' DECLARATION License Class 5 tic. #669850 Contractor J T CONSTRUCTION SERVICES INC Date 05/31/2017 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. hereby affirm under penalty of perjury one of the following two declarations: 1. 1 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. 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 10/19/2016 ISSUED: 10/19/2016 PHONE NO: (408) 234-4340 PERMIT INFO: X BLDG —ELECT _ PLUMB _ MECH _ RESIDENTIAL X COMMERCIAL JOB DESCRIPTION: STE 110; IST FLR, MEZZANINE; T.I. OFFICE (2,320 1 ST FLR, 752 MEZZANINE, TOTAL 3,072 S.F.) - GOLDEN VISION OPTOMETRY Sq. Ft Floor Area: I Valuation: $184500.00 APN Number: Occupancy Type: 316 20 112 A (Tenant Improvements),B (Tenant Improvements) PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. by: Kim Dunbar I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. 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 (Scc.7044, Business & Professions Code) z. ` 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: 10/19/2016 I 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 3706 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 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 10/19/2016 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 25534. Owner or authorized agent: Date: 10/19/2016 N AICY 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 ARC HITECT'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 950143255 CUPERTINO 1 (408) 777»3228 -FAX (408) 777-3333 ► buildinga0cupenin ort! �3 r ZD l . r Z L 5 f-1wrzwromgsmtlrnom n AT]r)1"OM :M AITt?RAnnK/Ti n REVISION1 DEFERRED ORIGINALPL-Uff#...-- P1107ECCAAt3RE15 114-51 C 1 VV %44 t.A"K 6�vv:� L10 AVN# OWNER NAME _ i ZMOW t / [ A GONE Q �, FrMAIL STREET ADDRESS J Ate] G� 5 +. i + n r J� �C1TY STATE, 7JP R£ 4 FAX CONFACt NAME PYI ;4 L4 51- J1I. >rMATL era .1.44 G ST"erACQRESS,J 5q, i,J +/ .S `\[ C W, STATE 7SP r r40 L�CA:VN FAX 1 11 OWNRR ❑ owmr BUILDER IKOwNER AGm ❑ CONTRACTOR ®CONrRACTQR AGENT 0 ARGHn"FiCI' l3 EmowEm 13 OHYLi OPW E3 TENANT CONMCTORNAME� ... LICENSHNUMBM /Y ED] LICENSE TYPE BUS.LIC 9 COMPANY NAME.W. g &MAIL—^'e-� y IrAX 5MFT ADDRf.SS 17,90 024 AVC— Vd T 3 CrrX, StATC? ZiP 6.LICENSENUMURR PHO ARCHFCECTIENGINELRNAMIE 4 S L BUS. LIC .9 COWANYNAMH V MAIL FAX STREETADDPXSS { 1 i.• I C",STATF,73P � ' , f G> Q (��-Ea — (�j�tJV DMrR _ 41.01'-'-Y_02LK _ _:{rte '` •, 9©S LVar �M z �Ni � 7 -r-TA-t- t `3c S EXISTINGUSE PROPOSEDUSE CON57R T 7YP8 #STORIES ! USE TYPE UCG SQ Ft. ! VALUATION (S) PxtsTa NWFLOO AREA J ,�' j AREA DPMO TOTAL (�- AREA .NBT AREA + 6 7 �T' r t /t j ,t BATHROOM KH'CREN OTWK RibMODMARRA RIWODELARIsA RrWODFLAREA - PORCH AREA AR13fl TOTAL WACirt►'aRCtr AREA WADECK GARACI? ARi�: 11[iTACH ATrACH R DWFI.LWCI UNITS: - rSASECa)[VD W'Ir7' YES DIEING AIMED? ONO SECOND STORY ❑YF.S - ADDITION? ®No PRE-APMJCATtON I�YF5 1FYFS,PRQVIDECOPYOF ISTIMM' 6'AN .❑YES , TOTAL ALUATION. .. PtAMINGAPPLb ©NO FLAMING APPROVALLSTTER. EiCHLERHOMR7 ©NO By lny 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 haver ad this application and the information I have provided is correct. ave read the Descriplion of Work and verify it is accurate. i agree to comply with all applicable local ordinances and state laws minting to building cons I u FresentaHves of Cupertino to eater the abow-Ideriffvd for inspection pwposes. Signature of Applicant%gent. Date: ^ SUPPLEMENTAL INFORMATION REQUIRED t;oM AN CHYCKTYPE Rotrrt*tGsttr ❑ OVS&•Tur eau tk © BMLDtNG PLAN MUW _ New SFD or Multifamily dwellings: Apply far demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. 0. EXPUPss D PLANNYNG Pt.ArI Rxvmw — Commercial Bldgs: Provido a completed Hazardous Materials Disclosure C3 STANDATM D ruartc W01tKq form if any Hazardous Materials are being used as part of this project. Cl LA114A © VIFM IDZVr —Copy of Planning Approvai:Lctter orMecting with Planning prior to ❑ MAJOR ❑ S&WARYSIEWER DISK T submittal of BuildingPermit application. 0 RNVIRO vM1tF N i Ai. llt hE.! !t B1dgApp 3011,doc revised 06121111 M t