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B-2016-1423CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CON'T'RACTOR: PERMI NO: 19333 'VALLCO PKWY CUPERTINO, CA 95014 (316 20 076) (CUPERTINO C) 01 ELECTRIC t SAN JOSE, CA 95112 OWNEWS NAME. Apple DATE I SURD. 2!24/16 OWNER'S PHONE: PHONE O: 40.8-8D8-8016 LICENSED CONTRACTOR'S DECLARATION BUILDING PEI?IVHT INFO: License Class Lie. # 1-144 S-7 C, Contractor LQ_UEERTINO ELECTRIC INC) Cate � � X BLDG X ELECT _ PLUMM I hereby affirmthat I am licensed under the provisions of Chapter 9 (commencing _ MECH _ RESIDENTIAL X Oho MIERCIA_L with Section 7000) of Division 3 of the Business & Professions Code and that my license is in fall force and effect. JOB DESCRIPTION: INSTALL (1) 4" LOW VOLTA G CONDUIT FROM EXISTING I hereby affirm under penalty of perjury one of the following two declarations: PARKING LOT VAULT TO EXISTING LOW 'VOLTAGE TELCO VAULT L I have and will maintain a certificate of consent to self -insure for Worker's IN COURTYARD 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: Valundor t $44950.00 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: Occupaney'Tg'pe: ordinances and state laws relating to building Construction, and hereby 316 20076 authorize representatives sof 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 :[RIOT STARTED expenses which may accrue against said City in consequence of the of this permit. Additionally, the applicant understands and will WITHIN 180 DAYS OF PERMIT ISSUANCE OR comply with all non -point source regulations per the Cupertino Municipal 180 DAYS I+' M LA T GALLEIN INSPECTION. Code, Section 9.18. Issued b y: 4 Signature Cate �Q (, Date: - OWNER-BUILDEItAECLARATION �✓� RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law far one of the All roofs shall be inspected prior to my 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 t. 1, as owner of the property, or my employees withwages 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. 1, as owner of the property, am exclusively contracting with licensed Date: contractors to construct the project (See.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOK' CONE RINGS TO BE CLASS "A" OR BETTER a. 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 requireirnents under Chapter 6.45 of the z. I have and will maintain Worker's Compensation Insurance, as provided for California Health & Safety Cod-, 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 Cup) artino Municipal Code,, Chapter 9.12 and the this permit is issued. Health & Safety Code, Section 2 532(a) should I store or handle hazardous 3. I certify that in the performance of the work for which this permitisissued, l material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area AIT Quality Management District I shall not employ any person in any manner so as to become subject to the will maintain compliance with the upertdno Municipal Code, Chapter 9.12 and Worker's Compensation laws of California. If, after making this certificate of the Health & Safety d , Sections 25505, 25533, and 25534, exemption, I become subject to the Worker's Compensation provisions of the Q Labor Code, I must forthwith comply with such provisions or this Hermit shall be deemed revoked. Owner o pt orized agent: Date: APPLICANT CERTII YCATION CONSTRUCTION LENDII�IG ACliN'CX- I certify that l have read this application and state that the above information is I hereby affirm that there is a construction lending agency for a performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is is ued (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 ARCHITE' T'S I3l CLQ RATI tT 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 usE d as public records. Cupertino Municipal Code, Section 9.18. Licensed Professional Signature Date GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT, BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014=3255 (408) 777-3228 ® FAX (408) 777-3333 d bullding@cupertho.org ❑PLUMBINCt F-1 MECHANICAL RIBLECTRICALMlk CcELL MISIC hl U PR0JECT ADDRESS APN 01MERttAME Apple PHONE f-t4AFI. STREET ADDRESS CITY, STATL,' ]J0 ` c ACT I PHON ". 5-11 -U Lf B- MAIL trv�.SS. 3 CcS�cy (Le-1, . .I X-I- l'C77A—DDO cS eyPt a / CIT SATLE, ZRae'.. L, W— q T la' FAX © OIVNER AOENT lX CONTRACTOR Q CONTRAC'7'Olt AGENT ❑ARCMTECT Q PNOI tsFR 0 MBLOPER M TENANT COM'IRACTORNAMBENUMBER Rick Z ra en LICENS 7 fi TCENSETYPE L010 SUS. LIC iF E COMP YNAAd _' ui�er ino Electric Ti MAiF. rlek z9ragen@cei.com FAX STRT;EjI])ES� SC�Jent�l4 ( i CITY, e �i 'S'�se CA 951 �? ry n L'FyZ-118-8x1 6 ARCHITECTIENGINEER NAME -T LICBMSE NUMt3EiR 3US:, LIC , COMPANYNAME E-MALL PAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF Cl SFDorD pux Q &IIJLTI-FA AIL BUILDING: COAJhILRCl+iL )LAND Q Y$5 U1t11.ANINTIiRPACEAIfF,ANO PROJEC:TM EI YES PLOORZON[i NO IS TI-B fiLDO AN YES ETCHLERHOAIE7 NO DESCRtPT10NOFtivGRIC ®� Install 1 4" low,vmlta e conduit from existing parking lot vault to existing low voltaic e telco vault in courtyard. TOTALVAWATION:44 0. RFCLIMT)Y: By my signnture Ue;oty, i certl£y to each nfilte following: I am the property owner or authorized 880111 to act on the inraper owl appticnfion and tllc infoantatloll.I lleu pl'ovicleci is correcl. 1 hove read the Descripdolt of Work Find verify it is acourato. I agr to ordinflaces and state lams m1 ing to tit" d' nstri,101 , uthorize. reprosentatives of Cupertino to cuter the above-identified p Signature of ApplicanilAgent: Date: 2-24-16 s Behalf. I have read this comply will) all applicable kcal apetly for inspection purposes. SUPPLEPAEINTALeAFIZMATION REQUIRED a a, Cr ORFICElisp ONLY ❑ 01,1TR-THE-COUNTER © mn-mg IJ STANDARD {� LARGIR ❑ TrLuon 1lICPtYlt c 1p��a 2GrI Ldoe revised t%f21/.1I ..I