14040100 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10200 S DE ANZA BLVD CONTRACTOR:CUPERTINO ELECTRIC PERMIT NO: 14040100
INC
OWNER'S NAME: SEAGATE TECHNOLOGY LLC 1132 N 7TH ST DATE ISSUED:04/16/2014
OWNER'S PHONE: 4086581187 SAN JOSE,CA 95112 PHONE NO:(408)991-1000
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL F1 COMMERCIAL ❑
INSTALL(4)OUTLET RECEPTACLES FOR FUTURE TV'S
License Class Lia.# P`
(2ND FLR)
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
,Iperformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$4000
11rave 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:36901035.00 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
to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes, (We)agree to save 180 DAYS FROM ION.
180 DAYS FROM
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 �Lmue ate:
L/
with all non-point source regulations per the Cupertino Municipal Code,Sectio��
9.1&
RE-ROOFS:
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
inspection.
11 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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)
1,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. 1 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 the Health&Safety Code,Sect' 5515, 533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this (!
permit is issued, Owner or authorized agent: Date:—
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 CONSTRUCTION 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
9,1&
Signature Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING bivisION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
(408)777-3228-FAX(408)777-3383-building(a)cuperting.org k\j
CUPERTINO
ElpLuNmiNG EIMECHANICALELEC TRICAL MISCELLANEOUS
:&—
PROJECT ADDRESS laoD -�Df" Aw7-A Zj\/cL - -1 AFN# 3�q Lj- 0 ) - o 3:5'
OWNER NAME ' —4p PHONEL6 I643S (IS7_ I E-MAI��aVD_A' terd
STREETADDRESS 200 1� Amvx c"Y,STATE,T,�Pc4ivio CA I FAx
CONTACT NAME tov
STREET ADDRESS CITY,STATE,ZIP FAX
0 OWNER 13 OWNER-BUILDER ❑ OW NERAGENT CONTRACTOR ❑CONTRACTOR AGENT 0 ARCHITECT 11 ENGINEER 11 DEVELOPER 0 TENANT
CONTRACTOR NAME -' LICENSE NUMBER I LICENSE TYPEC�d BUS.LIC#
COMPANY
t+ 11 ee-
STREET ADDRESS (�k <fTAPHONE
NE
CITY,S
AR lb210INEER AME LICENSE NUMBER BUS.LIC#
COMPANY NA,'vffi E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFDrDUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN 0 YES IS THE BLDG AN 171 YES
BUILDING: j!ZCONSfERCLkL URBAN INTERFACE AREA NO FLOOD ZONE ❑NO NO
DESCRIPTION OF WORK
�44
TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act onAe%--P--1ty Ix lus
application and the information I h r tied is correct.4 have read the Description of Work and verify it is accurate. I agree Tto comply with all applicable loc
ordinances and state laws relatin �.� I tio . I authorize representatives of Cupertino to enter theb tip d '4yfor inspection PuK)oses.
pror
2—
Signature of Applicant/5- 9�� Date:
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
El OVER-THE-COUNTER
❑ EXPRESS
❑ STANDARD
Z
El LARGE
❑ MAJOR
AEPMiscApp_,201 I.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10200 S DE ANZA BLVD DATE: 0411612014 REVIEWED BY: MELISSA
APN: 369 01 035 BP#; *VALUATION: 1$4,000 -�
PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARYCommercia{ Building PENTAMATION 10EAP10
USE: PERMIT TYPE: I
WORK INSTALL 4 OUTLET RECEPTACLES FOR FUTURE TV'S 2ND FLR
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Recep/Switch/Outsets 1BREMRECEP 4 ## $47
TOTALS: $47.00
:N, ; ._,. Elec.Plan Check 0.0 1 hrs $0.00
Elec.Permit Fee: IEPERMIT
/' WF >rT _> xtr „jF, Other Elec.Insp. OAhrs $47.00
NOTE. This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the relimina information available and are only an estimate. Contact the De t or addn'l in o.
FEE ITEMS (Fee Resolution 11-053� .' 711'132 FEE QTY/FEE MISC ITEMS
.
PME Plan Check: $0.00
Su'up , t ..
PME Unit Fee: $47.00
PME Permit Fee: $47.00
Administrative Fee: 1ADMIN $44.00
Work Without Permit? 0 Yes (F) No $0.00
Travel Documentation Fee: ITRA VDOC $47.00 A
Strang: Motion Fee: 1BSEISMIC0 $0.84 Select an Administrative Item.
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS $186.84 $0.00 TOTAL FEE: $186.84
Revised: 04/01/2014