12120019 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: I I I I I N WOLFE RD CONTRACTOR:BERGELECTRIC CORP PERMIT NO: 12120019
OWNER'S NAME: CUPERTINO VILLAGE LP 5650 W CONTINELA AVE DATE ISSUED: 12/05/2012
OWNER'S PHONE: 4088631276 LOS ANGELES,CA 90045 PHONE NO:(310)337-1377
EI LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class e-10 Lic.9 33q/8
MECH r RESIDENTIAL r COMMERCIAL r
Contractor f4,redPr_+r.L Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: STARBUCKS STE C-INSTALL ONE 20 AMP CONVFNIENCF
(commencing with Section 7000)of Division 3 of the Business&Professions OUfLET
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
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 ofthe work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$800
Section 3700 ofthe Labor Code,for the performance ofthe work for which this
permit is issued.
APPLICANT CERTIFICATION APN Number:31605072.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence ofthe 180 DAYS FROM LAST CALLED INSPECTION.
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' Issued by�� Date - {---
Signature Date I 2 T /Z
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. Its roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons:
inspection.
1,as owner of the
property,or my employees with wages az their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature ofApplicant: Date:
Business&Professions Code)
I,as owner ofthe property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one ofthe following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 ofthe Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
1 have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 ofthe Labor Code,for the performance ofthe work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued, contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance ofthe work for which this permit is issued,l shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,atter making this certificate ofexemplion,I Owner o au razed agent:
become subject to die Worker's Compensation provisions ofthe Labor Code,I must Date: )Z—tS/Z
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence ofthe ARCHITECT'S DECLARATION
of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used az public records.
9.18.
Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION 6 M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 Is
A
(408)777-3228• FAX(408)777-3333• buildina(G,cuoertino.oro
GUPERT{NO �`•(' V`
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❑PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELANEOUS
FR0.1EC1'ADDRESS 111.1 1 w� IiQL ; frN; ) os D�a
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DwNE2 NAME n0 v l PHO 8_g--4 -la -P
STREET ADDRESS ��Z 3 Q4J =' ��t IG .Y 110442 FAX
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CONTACT NAME .J PHONE E-MAIL
COrota'aL�A('
SIiZ -TADDRESS y// CITY,STATE, 7B FAX
13OwNEt ❑ OwNFR-BUTLOBt E3OWNF]t ACBNT' vt CONTRACTOR ❑CONTRACTOR Aom T. ❑ AacHIT r ❑r o:Ni ES:R. ❑ DEVELOPER ❑ TINANT
CONiRACTORN 11CBQSE14UMBER LICENSE TYPE BUS.LIC,Y
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COMPANYNAlae` .MAM k CR , lAln PAG-636 —1817 1
STREET ADDRESSCnX STATE,ZIP PHONE
1 vn Plrr G PC -636- 1880
AACHITECl/ENGRdIItNAIa LICENSE NUMBER BUS.LC R
COMPANYNAMEE-MAIL FAX
STREETADDRESS CITY,STATE,IIP PHONE
USE OF ❑SFD m DUPLEX ❑ MI1 WAMILY PROJECT IN WDDLAND ❑ M PROTECT IN ❑YES IS THE BLDG AN ❑YES
BLITLDWO: M16OMCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME! ❑NO
DESOUPTIONOFWORX II O v
r
TOTAL VALUATION: j RECEIVED BY: J
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 bebalf. 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
orcUrt ces and state laws relating to biAding cpYstruct)on. I authorize representatives of Cupertino to enter the above-identifiedprope:y forinspection put•,hoses.
Signatum of AwNcant/AgenC Date: I'L I S I I Z
SUP EMENTAL INFORMATION REQUIRED OFFICE SE ONLY
OVER-T.-COUNTER
❑ EXPRESS
U
❑ STANDARD
U
LARCE
❑ MAJOR
MEP?V acApp_2011.doc revised 0621111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: I1111Awolfe rd. C I DATE: 12/0512012REVIEWED BY: bob s.
APN: BP#: I *VALUATION: $800
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY Commercial Building PENTAMATION 10EAP10
USE: PERMIT TYPE: Al
WORK install new branch circuit with new outlet.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Recep/Switch/Outlets 1BREMRECEP 1 # $45
TOTALS: $45.00 {rs �
,Lfech. Plan Check Plumb,Plan Check Elec.Plan Check 0.0 hrs $0.00
;Lfech. Permit Fee: Plumb. Permit Fee: Elec.Permit Fee: IEPERMIT
Other,Much. Insp. Other Plumb Insp. Other Elec.Insp. 0.0 hrs $45.00
d-lech.Insp. Fcc: Plumb. Insp.Fee: Flee.Insp. Pec:
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 prelimina information available and are only an estimate Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 7(f /1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. lnsp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: 1dDMIN $42.00
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $45.00 A
Strong Motion Fee: IBSEISMICO $0.50 Select an Administrative Item
B1de Stds Commission Fee: IBCBSC $1.00
$178.501 $0.00 TOTALFEEi' $178.50
Revised: 10/01/2012