15120033 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15120033
10033 SAICH WAY CUPERTINO CA 95014(326 32 041) (SILICONX
CONSTRUCTION INC)
SAN JOSE,CA 95131
OWNER'S NAME: (SAICH WAY STATION LLC) DATE ISSUED:
' OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
•
License Class Lic.#
Contractor(SILICONX CONSTRUCTION INC)Date _BLDG _ELECT _PLUMB
MECH_RESIDENTIAL_COMMERCIAL
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. JOB DESCRIPTION:
H&R BLOCK-INSTALL TEMPORARY TRAILER FOR SERVICE
I hereby affirm under penalty of perjury one of the following two declarations: TO PUBLIC/EMPLOYEES FOR USE DURING CONSTRUCTION
1. I have and will maintain a certificate of consent to self-insure for Worker's (678 SQ FT).
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. Sq.Ft Floor Area: Valuation:$8000.00
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 APN Number: Occupancy Type:
ordinances and state laws relating to building construction,and hereby 326 32 041
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 PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will
comply with all non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION.
Code,Section 9.18.
Issued by:-1
Signature Date Date:
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1. I,as owner of the property,or my employees with wages as their sole inspection.
compensation,will do the work,and the structure is not intended or offered
for sale(Sec.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with licensed Date:
contractors to construct the project(Sec.7044,Business&Professions Code).
I herebyaffirmunder penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO-BE CLASS"A"OR BETTER
r. 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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation hrsurance,as provided for California Health&Safety Code,Sections 25505,25533,and 25534. I will
by Section 3700 of the Labor Code,for the performance of the work for which maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
this permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the 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
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authorized agent:
be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING 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
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued'(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally,the applicant
understands and will comply with all non-point source regulations per the I understand my plans shall be used as public records.
Cupertino Municipal Code,Section 9.18.
Licensed
Professional
Signature Date
1A4,19- 1 cK
TEMPORARY CERTIFICATE OF OCCUPANCY FORM , .. .-
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
ALBERT SALVADOR,RE,C.B.O.,BUILDING OFFICIAL Ti,-.0,, iii.,
i „,...„4.,
, ._ 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building a(7,cupertino.or r Dl / r
APN �l ) ` 1 BP#: p DATE/ / >
f 8 VALUATION: $ .SITE i
ADDRESS: 1cna fob 7.a.,),?-do,
OWNER'S NAME S0 1 t ei 5..wrt/ON FAX#HONE#,Clfee3)T5 6,
MAILING AD�1(if di rent�csite�address):A\' � 13 )' '� � C4-4•51-9/ ,
CONTRACTOR. j (.:.�� �� ,�}PHC7NE#; /l�� � � � l
r. 1(16n ') (41,13*-ruc ?X LFAX#: ( {
50
CONTACT: j ,�, PHONE# 6f 5-g/� J
I�ACD( , t 6(a l FAX#: 0g
TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION •
BOND TYPE: ❑ SURETY BOND AMOUNT (1% VALUATION 5 � CODE
❑CHECK 0 CASH BOND OF BOND: 5K min-10K max
1 (BLDBONDSJ EDITION:
TCO EXPIRATION
FEE. $286.00/ 0 TOTAL FEE: $ .1 [IT1=MPOCCJ
DATE(6 MONTHS MAX):
USE TYPE OF FLOOR OCC LEVEL COMMENT
CONSTR AREA LOAD
OTHER DEPARTMENT.!AGENCY APPROVALS:
Planning
0 APPROVED, 0 APPROVED WITH CONDITIONS*
Signature: Date:
Fire )/ ,t t
Signature: Date:3 . 7., 7„, t APPROVED ❑ APPROVED WITH CONDITIONS' i
PublicWorks
Signature: Date;
❑ APPROVED 0 APPROVED WITH CONDITIONS”
Other:
Signature: Date: ❑ APPROVED 0 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
may result in an enforcement action. _
Owner Contractor
Signature: Date: Signature Date:
This temporary certificate ensures that all fire protection and life safety systems have been completed,inspected,successfully tested and
pproved for the specific a a of th- bu •in. s.scif'e bone torvide_p easonab deg e of afety toth occu ants f o f`oiand
:,imilar emergencies:•. jF �i •) �.it1 ( C t C1 ,.- &-;- ---�a �C.
Building Official: I LOc d� Print... S4/--0.5: Date:. /1 /J.6
DEPARTMENT ACTION: After determination,copies to: 1)applicant, 2)permit file ` d
— TenrpOccForn_2013.doc revised 7/7/14
PERMIT FEE RECEIPT
Case # 15120078
a6T."rs Date Printed: 03/18/2016
CUPERTINO
CITY OF CUPERTINO -FEES RECEIPT
Permit Summary
Case Number: 15120078 Permit No: 15120078
Project Valuation: 80000.00 Date Submitted: 12/08/2015
Permit Type: 1B TI
Address!APN: 10073 SAICH WAY(326 32 041) Receipt#: 202757
Scope of Work: H&R BLOCK-T.I.TO BUILD OUT SHELL FOR B
OCCUPANCY(1,515 S.F.)
Contacts
Contact Type: Applicant
Company Name: SAICH WAY STATION LLC Primary Phone: (408)595-9596
Full Name:
Address: 2051 JUNCTION.AVE STE 100 SAN JOSE,CA 95131
Contact Type: Property Owner
Company Name: SAICH WAY STATION LLC Primary Phone: (408)595-9596
Full Name:
Address: 2051 JUNCTION AVE STE#100 SAN JOSE,CA 95131
Fees
Fee'slrifarnjafion z •_:;•_-,=`-: r Amoiiit
Building-Bond $5,000.00
TCO GOOD TILL 4/18/2016
Temporary Occupancy $286.00
TCO GOOD TILL 4/18/2016
_-c-��:.: _,=;•�. .
Y!m�nt=Date====
;.;;.w.:::,,- -:-.
Building-Bond 0311812016 ROCCI GRAY Credit Card $5,000.00
Temporary Occupancy 03/1812016 ROCCI GRAY Credit Card $286.00
FEE TOTAL $5,286.00
AMOUNT PAID $5,286.00
BALANCE DUE $0.00
03/18/2016-9:02:57 AM-Generated by:paulos
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