12120021 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20520 STEVENS CREEK BLVD CONTRACTOR: BERGELECTRIC CORP PERMIT NO: 12120021
OWNER'S NAME: MARDESICH CO CROSSROADS LLC 5650 W CONTINF.LA AVE DATE ISSUED: 12/052012
OWNER'S PHONE: 4082553042 LOS ANGELES,CA 90045 PHONE NO:(310)337-1377
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class t,110 Lic.N 33518 F r F
MECH RESIDENTIAL COMMERCIAL
Contractor a nL Date Mls- 1'Z
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:STARBUCKS-INSTALL ONE 20 AMP CONVENIENCE
(commencing with Section 7000)of Division 3 of the Business&Professions OUTLET
Code and that my license is in full force and effect.
1 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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$800
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APN Number:35908018.20520 Occupancy'rypc:
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 of the 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' nn Issued Date:
U
Signature �� Date 1215 aZ
❑ OWNER-BUILDER DECLARATION RE:ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a 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 as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sce.7044, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the 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 of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE:
1 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 of the 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&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 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 of the work for which this permit is issued,I 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,after making this certificate of exemption,I Owner o aut 'zed agenC
become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 7Z-
I'orthwith 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.1 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 of the ARCHITECT'S DECLARATION
granting 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 as public records.
9.18.
Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION 15�iW E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
( 08)TORRE AVENUE(E•;UP-3333-, CA 950143255 / �/ �M ' A C
CUPERTINO 408 777-3228• FAX 408 777-3333•buildinG(G)cuoeriino.orG a `\j
El PLUMBING ❑MECHANICAL 50EU=CAL ❑MLSCELLANEOUS
PROJECTADDRESS 2oS 20 x J.�l�d• AP"',
CT 35V CIV
OWNERNAIAS PHONE O _ -30 E-MAM
STREETADDRESS �J`Y" �G^� CRY, STATE,ZZCU %,10 Cc. q,6 - FAX
CONTACT NAME _ „y _ PHONE E-MAIL
STREEI'ADDRESS -V CITY,STATE,ZIP FAX
❑ OWNER ❑ OwKm-BUILDER ❑ OWNER AGBNTCr ❑CONTRACTOR AGENT. ❑ ARCF7P_CT ❑ENGINEER ❑ DEVELOPER. ❑ TENANT
140
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STR.EFTADDRESS CRY,ST Z!P PA
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ARCHMMENGJNE tNANM LICENSE NUJdBR BUS.GC.
COMPANY NAME E-MAIL FAX
STREETADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD.DUPIFX ❑ MULTI-FANOLY PRWECT DI WILDLAND ❑ Y-.5 I PROJECTIN ❑YES ISTli-a BLDGAN ❑ YEB
Bt=ING: CAM CIAL URBAN INTaFACEAREA ❑ NO FLOOD ZONE ❑No EIl'FDJt HOME? ❑NO
DESCRIPTION OF WORK
n l l � girt. vi'1
TOTAL VALUATION: x RECEIVED BY: �-
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 behalf. I have read this
application and the information I have provided is correct. I have=d the Description of Work and verity it is accurate. I afire-w comply with all applicable local
ordinme_-s and sate laws relating to buildin cons ction I authorize r-presentativa of Cupertino to enter the above-identifiedpropc y for inspcction puChoses.
Signature ofApolicanNAgent Date: f7--5-1 Z
SUPP AL INFORMATION REQUIRED OFFICE USE ONLY
yr COVER-THE-COUNTER
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F ❑ EXPRESS
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❑ LARGE
❑ MAJOR
MEP:LfucApp_011.doc revised 06/21/11 -
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 20520 stvns crk blvd 1st floor DATE: 12/05/2012 REVIEWED BY: bobs.
APN: BP#: / 0,0Q� 'VALUATION: $800
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY Commercial Building PENTAMATION 10EAP10
USE: PERMIT TYPE:
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
a ° 4 _v
Nfaeh. Plan Check Plumb. Plan Check Elec.Plan Check 0.0 hrs $0.00
:Lfe& Permit Fee: Plumb. Permit Fac': Elec.Permit Fee: IEPERMIT
Other dlech. Insp, Other Plumb Insp. Other Elea Insp. 0.0 hrs $45.00
Adech. Insp. /4+c•: Plumb. hap. Fee: Glec.Insp.Fee.
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on therelinnina in ormatlon available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee
Suppl. PC:Fee
PME Plan Check: $0.00
Permit /site:
Suppl. hr.sp Fee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Consiruclion Tac:
Administrative Fee: IADMIN $42.00
Work Without Permit? 0 Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: 1TRAVDOC $45.00
Strong Motion Fee: IBSEISMICO $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
j $178.50 $0.00 . TUTAL'FEE. $178.50
Revised: 10/01/2012