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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 .: .:. ire 1/ Signature: Date: q❑ APPROVED ❑ APPROVED WITH CONDITIONS* u is o Signature ❑ APPROVED . .... 6. ❑ 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 ' �• � 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 # : / 2 q DATE: OCC LOAD VALLUAT� ION: 14 Z_ ! ❑ 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:............... .S CONTRACTOR: /G /� �r PHONE #: FAX #: �c3� /- mil% 'f - el 5 3 CONTACT: / 0 : _ 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 :....... ... u is Wor _ .. .. .............................. �Ywir� Da ......... 6 �� ❑ APPROVEDPPR VED ITH CONDITIONS* Signature:.. .... .. ........... ........................ e:............... .S ter: APPROVED �TUCO ncnAwrRACKIT / ArzeIJCv APPR(1VA1 C• anning Si nature:..,.. ,�.:...... ' '.�ti� ......... Date: ............ ;�.. APPROVED ❑APPROVED WITH CONDITIONS* Fire Date:....... ❑ APPROVED ❑ APPROVED ITH CONDITONS*c Signature :....... ... u is Wor _ .. .. .............................. �Ywir� Da ......... 6 �� ❑ APPROVEDPPR VED ITH CONDITIONS* Signature:.. .... .. ........... ........................ e:............... .S 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