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15030142 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10555 MARY AVE CONTRACTOR:CUPERTINO ELECTRIC PERMIT NO: 15030142 INC OWNER'S NAME: CITY OF CUPERTINO 1 132 N 7TH ST DATE ISSUED:03/24/2015 OWNER'S PHONE: 4087773228 SAN JOSE,CA 95112 PHONE NO:(408)991-1000 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL ❑ INSTALL ONE(N)DUAL-HEAD EV CHARGING STATION; License Class C_1b1B,C 1 C 9l ic.# NEW Contractor QvPmt1N-o 6_a,`t�°.IC,1NCDate b3 2`M S 100 AMP PANEL. 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$27500 1 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:32606052.00 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.1 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 DAY771,ST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the �c� granting of this permit. Additionally,the applicant understands and will comply Issued by: Dat . with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I J RE-ROOFS: Signature Q�� Date All roofs shall be inspected prior to any roofing material being installed. If a roof is c installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION 1 hereby affirm that[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) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). 1 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 1 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,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: permit is issued. 1 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 1 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.I8. Signature Date ALTERNATIVE ENERGY PERMIT APPLICATION 0\ COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION � A 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 ( O (408)777-3228•FAX(408)777-3333•building(&cupertino.org CUPERTINO PROJECT ADDRESS 10555 Mary Ave., CA, 95014 APN# 3 Z 6 Q Q S Z _7OWNERNAME City of Cupertino PHONE 408-777-3228 E-MAIL AlexA@cupertino.org STREETADDRESS 10300 Torre Ave. CITY, STATE,ZIP Cupertino, CA, 95014 FAX 408-777-3333 CONTACT NAME PHONE E-MAIL Alex Acenas 408-777-3232 AlexA@cupertino.org STREET ADDRESS CITY,STATE,ZIP FAX RI 10300 Torre Ave. Cupertino, CA, 95014 408-777-3333 RI OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME Luke We ener-Verna a0 LICENSE NUMBER 174637 LICENSE TYPE BUS.LIC# g g C-10,B,Ca,C-46 697 COMPANY NAME E-MAIL FAX Cupertino Electric, Inc. Luke Wegener-Vernagallo@cei.co STREET ADDRESS 1132 N 7th St. CITY,STATE,ZIP San Jose, CA, 95112 PHONE 408-813-1636 ARCHITECT/ENGINEER NAME Gustavo Couto LICENSE NUMBER E 20493 BUS.LIC# 697 COMPANY NAME E-MAIL FAX Cupertino Electric, Inc. Gustavo_Couto@ cei.com STREET ADDRESS 1132 N 7th St. CITY,STATE,ZIP San Jose, CA, 95112 PHONE 408-808-8101 USE OF ❑ SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: Q Commercial URBAN INTERFACE AREA ❑ Yes ® No FLOOD ZONE ❑ Yes IXC No ❑SOLAR PANELS Ix1 ELECTRIC VEHICLE CHARGING STATION ❑ SOLAR WATER HEATING ❑ OTHER: FOR SOLAR PANELS. NUMBER OF PANELS/UNITS: KILOWATTS(COMMERCIAL ONLY): I ♦ TOTAL VALUATIOq7;",7 DESCRIPTION OF WORK / *'1[— Engineering and installation of one (1) dual-head charging station for the City of Cupertino. Charging station to be installed in the parking lot of the City's Corporate Yard. By my signature below,I certify to each of the following: I am the r e owner or authorized agent to act on the prope w e . have read this application and the information I have provi ed is correct. I have re e escription of Work and verify it is accurate. I agre comply with all applicable local ordinances and state laws relating to buil ' cont tion. uthoriz p sentatives of Cupertino to enter the above-identi led pro erty for inspection purposes. Signature of Applicant/Agent: Date: 3 .2 2 SUPPLEMENTALDNIFORVATION REQUIRED OFFICE USE ONLY W OVER-TAE-COUNTER a E" ❑ EXPRESS U ❑ STANDARD U a ❑ LARGE a ❑ MAJOR PVApp 201 Ldoe revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10555 MARY AVE DATE: 03/23/2015 REVIEWED BY: MELISSA APN: 326 06 052 BP#: "VALUATION: 1$27,500 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION SOLAR-COMM USE: PERMIT TYPE: WORK INSTALL ONE N DUAL-HEAD EV CHARGING STATION NEW 100 AMP EL PANEL DEDICATED SCOPE CIRCUITS AND ASSOCIATED BREAKERS. Elec.Plan Check0.0 hrs $0.00 Elec.Permit Fee: IEPERMIT EIETOther Elea Insp. 0.0 hrs $48.00 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 preliminar information available and are only an estimate. Contact the Dept./or addn 7 info. FEE ITEMS Fee Resolution 11-053 E{f. 7/1/13FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # Alternative Energy System Suppl.PC Fee: (F) Reg. 0 OTT 0.0 hrs $0.00 $109.00 ICHRGSTA7 EV Charging Station PME Plan Check: $0.00 100 amps Electrical Permit Fee: $0.00 $48.00 IBELEC200 Services Suppl. Insp. Feer Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Pen-nit Fee: $48.00 Administrative Fee: 1ADMIN $45.00 0 Work Without Permit? 0 Yes (D No $0.00 G Advanced Planning Fee: $0.00 Select a Non-Residential 0 Travel Documentation Fee: ITRA VDOC $48.00 Building or Structure 0 i Strong Motion Fee: IBSEISMICO $7.70 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $150.70 $157.00 TOTAL FEE: $307.70 Revised: 0211 412 01 5