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13080141 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21979 SAN FERNANDO AVE CONTRACTOR:UNITED SITE SERVICES PERMIT NO:13080141 OWNER'S NAME: CITY OF CUPERTINO 50 WASHINGTON ST STE 1000 DATE ISSUED:08/20/2013 OWNER'S PHONE: 4086090424 WESTBOROUGH,MA 01581 PHONE NO:(508)594-2504 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALS License Class La std Lic.# $9.3,55 3 ` INSTALL TEMP POWER Contractor 010 .56_9d-Date Ad I hereby affirm that I am licensed under the provisions o 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:$500 I have and will maintain Worker's Compensation Insurance,as provided for by ection 3700 of the Labor Code,for the performance of the work for which this APN Number:35710008.00 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 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 DAMOOM LAST 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 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:C.Y• with all non-point sou ce regulations per the Cupertino Municipal Code,Section 9.18. 9 RE-ROOFS: Signature Date t�d `7 — 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. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby a .rm that I 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. 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 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 Cu ertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 05 553 and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: b o� permit is issued. 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City inconsequence 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 L 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 0i CUPERTINO (408)777-3228•FAX(408)777-3333•building(d)cupertino.ora MISC �3 t ❑PLUMBING [—]MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS �/ �� y� �.�1PN# OWNER NAME P ONED ,✓ � � E-MAIL STREET ADDRESS ®_ b CITY,STATE,Z FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMEOCl - LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SIT)u DUPLEX ❑ 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 no /� o TOTAL VALUATI j 6Q w RECEIVED B By my signature be o ,I certify to each of the following: I am the property owner or authorized agent to act on the operty owner's behalf. I have read this application and th ' ormation I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to mply with all applicable local ordinances ands to laws relating to build' nstru 'on. I uthorize representatives of Cupertino to enter the above-identified p for spection purposes. Signature of Applicant/Agent: Date: S7 EMENTAL INFORMATION REQUIRED IOYFICE USE ONLY W ❑ OVER-THE-COUNTER ❑ EXPRESS k v ❑ STANDARD v Z ❑ LARGE a ❑ MAJOR MEPMiscApp_201 Ldoc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21979 san fernando DATE: 08/20/2013 REVIEWED BY: Mendez APN: I BP#: 'VALUATION: $500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION 1 CEAP14 USE: PERMIT TYPE: WORK install temp power SCOPE . a WIM 'tech.Plan Check Plumb. Plan Check Elec.Plan Check 0.0 hrs $0.00 rLlech.Permit Fee.: Plumb.Permil Fee: Elec.Permit Fee: 1EPERMIT C)rher;ll,ch.Insp. {Jther Plumb Insp. Other Elec.Insp. O.0 hrs $47.00 Hech. Insp. Fee: Plumb. hrsp.Fee: Elec.Insp.Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These fees are based on the prelimina information available and are only an estimate Contact the De t or addn'1 info. FEE ITEMS(Fee Resolution 11-053 E . 7ff 11112) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 I amps Electrical Suppl.PC Fee: (j) Reg. 0 OT r070 I hrs $0.00 $47.00 1ECT<200 Temporary Power PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee-0 Reg. Q OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 Conso-fiction Tax: F_7 Administrative Fee: IADMIN $44.00 Work Without Permit? ® Yes (E) No $0.00 1 1 E) Advanced Planning Fee: $0.00 Select a Non-Residential G Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure Strong-Motion Fee: IBSEISMICO $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 $139.50 $47.00 ._ ,� $186.50 Revised: 07/01/2013