15010067 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20863 STEVENS CREEK BLVD CONTRACTOR:CUPERTINO ELECTRIC PERMIT NO: 15010067
INC
OWNER'S NAME: STEVENS CREEK OFFICE CENTER ASSOC 1132 N 7TH ST DATE ISSUED:01/12/2015
OWNER'S PHONE: 4089961010 SAN JOSE,CA 95112 PHONE NO:(408)991-1000
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL E]
APPLE-ADD WIREMOLD 15"; INSTALL(2)DOUBLE
License Classr.ID Lic.#T - (p �' DUPLEX
'_,' RECEPTACLES; RELOCATE 208V RECEPTACLES INTO
Contractor pate ' ` NEW
hereby affirm that 1 am licensed under the provisions of Chapter 9 WIREMOLD; INSTALL(2)280V 3PH CIRCUITS
(commencing with Section 7000)of Division 3 of the Business&Professions
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 of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$10000
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:32632053.20863 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, DAYS �F 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 DA ROAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which ma Accrue against said City in consequence of the
granting of this permit. Addh nally,the applicant understands and will comply Issued by: Date:
1,1oh 5--
with all non-po s rc e lations per the Cupertino Municipal Code,Section
9.18.
s RE-ROOFS:
Signature Date � All roofs shall be inspected prior to any rooting material being installed. If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that 1 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. 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 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equip nt 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 A Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with th upe o Municipal Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sect' s 5 2 53 ,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this 1
Owner or authorized agent:
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
1 certify that I have read this application and stale 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
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
M4
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
MISC
CUPERTINO (408)777-3228•FAX(408)777-3333•building(c)cupertino.org
❑PLUMBING ❑MECHANICAL LECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS A P N#,3,2
OWN F� J � P O E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
COYWCTCk NAME ^ LICE E N MBER�� LICENSE TYP BUS.LI #
AJn
COMP NAM l� E-MAIL �i FA
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STREETADDRESS CIT STYE,ZIP PHONE O_�6�
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in
ARCHITECT/ENGINEER NAM if - LICENSE NUMBER BUS.LIC#
COMPANY NAME •�/ E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF EI SFD or DUPLEX [I MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
C, N &-
TOTAL VALUATIO4 O RECEIVED BY:
By my signature below,I certiAeld
ollow' I am the property owner or authorized agent to act otrthe perry owner's behalf. I have read this
application and the informationis c I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relatin. authorize representativesof Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: 1-9
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OVER-THE-COUNTER
❑ EXPRESS.
U
❑ STANDARD
U
Z
❑ LARGE
a
❑'MAJOR
MEPMiscApp 2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 20863 seb DATE: 01/12/2015 REVIEWED BY: Mendez
APN: BP#: `VALUATION: $10,000
'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1 GENCO A
WORK apple- add wiremold 15 install 2 double duplex receptacles; relocate 208v receptacles into new
SCOPE wiremold; install (2) 280v 3ph circuits
Ll Lj
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'l info.
FEE ITEMS (Fee Resolution 11-053 Ell,' 7%1!131 FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 hours Plan Check, Hourly
Suppl. PC Fee: E) Reg. Q OT 0.0 hrs $0.00 $143.00 1STPGNCK
PME Plan Check: $0.00
Permit Fee: Hourly Only? 0 Yes Q No $0.00
Suppl. Insp. Fee:Q Reg. Q OT 0,0hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
0
Work Without Permit? 0 Yes ) No $0.00 G
Advanced Planning Fee; $0.00 Select a Non-Residential 0
Building or Structure 0
Strong Motion Fee: 1BSEISMICO $2.80 3.0 hrs Inspections
Bldi4 Stds Commission Fee: 1BCBSC $1.00 $429.00 ISTINSP Inspection,Hourly
SUBTOTALS: $3.80 $572.00 TOTAL FEE: 1 $575.80
Revised: 01/0 15