B-2018-1983 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1983
23600 VIA ESPLENDOR CUPERTINO,CA 95014-6516(342 54 016)123500 CRISTO QUIRING GENERAL
REY DR CUPERTINO,CA 95014-6527(342 54 999) LLC
FRESNO,CA 93727
OWNER'S NAME: DATE ISSUED:05/23/2019
OWNER'S PHONE:650-944-0112 PHONE NO:(559)432-2800
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#973147
Contractor QUIRING GENERAL LLC Date 05/31/2020 X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
THE FORUM-T.I.HEALTH CARE CENTER-(105557 SF)
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.
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:$2300000.00
APPLICANT CERTIFICATION
1 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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 34254016 R(Tenant Improvements)
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant u derstands and will comply with all non-point
source regulatio s per the u ertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05/23/2019 Issued by:Jasmine Archbold
Date:05/23/2019
OWNER-BUIL ER DEARATION
I hereby affix that I a exempt from the Contractor's License Law for one of the RE-ROOFS:
following two easons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I, s 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
c mpensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. 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:05/23/2019
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
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
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino nicipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sec ons 5,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05/23/2019 k
I certify that I have read this application and state that the above information is TR TPN i�NDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a co truction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit ig issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 05/23/2019 Professional
CONSTRUCTION PERMIT APPLICATION
..............-
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE e CUPERTINO, CA 95014-3255
(408)-777-3228 * building@cuperfino.org PEMIT#B-
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION Z T.I. 0 MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRESS APN#
23500 Christo Rey Drive,Cupertino,CA 95014 342-54-052
OWNER NAME PHONE E-MAIL
The Forum at Rancho San Antonio 650-944-0112 nancykao@theforumusa.com
STREET ADDRESS CITY, STATE,ZIP
23500 Christo Rey Drive Cupertino,CA 95014
[E CONTRACTOR NAME 1771 OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
,Paul Quiring Puiring General, LLC 1973147 13- General Contractor
ISTREET ADDRESSSTATE, ZIP
15118 E Clinton Way EFCIrTe'no, CA 93728
E-MAIL PHONE BUS.LIC#
dprieto@quiring.com 559-432-2800 404274
Z ARCHITECT [:1 OWNER [:1 OWNER AGENT El CONTRACTOR AGENT[:1 ENGINEER El DEVELOPER [I TENANT
CONTACT CONTACT NAME E-MAIL
Kathryn Dunn, Smith Group kathryn.dunn@smithgroup.com
C NTAC'
STREET ADDRESS CITY,STATE,ZIP PHONE
0
301 Battery St,7th Floor San Francisco, CA 94111 415-365-3445
DESCRIPTON
01
Interior renovation to an existing assisted living facility.
E]SINGLE-FAMILY/DUPLEX Mx MULTI-FAMILY ❑INDUSTRIAL ❑COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION
R2.1
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM ST SF SF 10,557 SF ❑DETACHED R2.1 10,557 SF 2.3 million
EXISING YES EICHLER ❑YES SECOND STORY ADDITION M YES
FIRE SPRINKLERS❑NO NO NO
DWELLING SECOND DWELLING E]YES []ATTACHED[1 DETACHED OTHER
UNITS# UNIT ADDITON: NO SF
POOLS F []FIBERGLASS []VINYL-LINED []GUNITE ❑PREFABRICATED
POOL-SF SPA-SF SPA ATTACHED El YES El NO TOTAL-SF aq
RECEIVED BB TOTAL VALUATION:
Commercial or Multi-Family Buildings with Public Swimming Pools requires DQ?artinent of Environmental Heath approval 2.3 Million
RE-ROOF EXISTING ROOF TYPE: F]BUILT-UP ROOF 7 ASPHALT SHINGLES[—]WOOD SHAKES❑WOOD SHINGLES[]TIL f OTHER(SPECIFY)
-]3/8" PLYWOOD TYPE: PITCH:
REMOVE/REPLACE M NO I IF NO PLYWOOD F�'/2" F ROOF CLASS
El YES #OF LAYERS THICKNESS[]5/8" OTHER ❑OSB ❑CDX OTHER •12 A
PROPOSED ROOF TYPE: DBUILT-UP ROOF DASPHALT SHINGLES 13 WOOD SHAKES DWOOD SHINGLES 171 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 purposes. I acknowledge and authorize all information contained on this application form
to be made available for public record.
Digitally signed by Kathryn Dunn
Signature of Applicant/Agent: Kathrwl D,inn t--jnl 0 1 1 nQ I_7.n-).r1_7 r101nfl' Date: 11/19/2018
SUPPLEMENTAL INFORMATION REQUIRED
*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
BldgApp-2017.doc revised 08101117