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B-2016-1695 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1695 22350 HOMESTEAD RD CUPERTINO,CA 95014-0116(326 01018) LIN R ROGERS ELECTRICAL CONTRACTORSINC ALPHARETTA,GA 30005 OWNER'S NAME: HARRINGTON THOMAS E TRUSTEE DATE ISSUED:04/05/2016 OWNER'S PHONE:408-636-1850 PHONE NO:(770)772-3400 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C�1 Lic.#5aA017 Contractor LIN R ROGERS ELECTRICAL CONTRACTORS INC Date 12/31/2017 X BLDG X ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL X COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: PEETS COFFEE-INSTALL 3(N)RECEPTACLES I hereby affirm under penalty of perjury one of the following two declarations: 1. 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 OPPEE� the work for which this maintain Worker's Comas provided for by fthe Labor Code,for thework for which this . Sq.Ft Floor Area: Valuation:$2500.00 APPLICANT CER11FICATION 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 APN Number: Occupancy Type: ,and state laws relating to building construction,and hereby authorize 326 01 018 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,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the:granting of this permit. WITHIN 180 DAYS`OF PERMIT ISSUANCE OR Additionally,the�applicant understands and will comply with all non-point source regulaon per,n �0—artinoMulCode,section 9.18, 180 DAYS FROM LAST CALLED INSPECTION. v'Signature iP` Date 4/5/2016 Issued by:Abby A,e�de, Date:04/05/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law,for one of the RE-RQOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. sale(Sec.7044,Business&Professions Code) 2. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:4/5/2016 t hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. 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. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6,95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. i will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9,12 and the s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino nicipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cgfle,Sg ti 05,25 3,and 25534. Labor Code,i must forthwith comply with such provisions or this permit shall ! be deemed revoked. I � �� Owner or authorized agent:( _ APPLICANT CERTIFICATION 1 Date:4/5/2016 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the-City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18, l understand my plans shall be used as public records. Signature Date 415/2016 Licensed GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTIN.O,CA 95014-3255 CUPERTINd (408)777-3228+FAX.(408)777-3333•building()cuaerfino.ora MISC PLUMBING MECHANICAL FIELECTRICAL MISCELLANEOUS PROJECT ADDRESS 22350 Homestead Rd,Cupertino,CA 95014 APN9 OWNER:NAME Peets Coffee PHONE 408-636-1850. STREET ADDRESS 22.350 Homestead Rd, CITY, CA 95014 FAX CONTACT NAME Lin R Rogers Electrical Contractors, Inc. PHONE 770=772-3487 E MATT. license@lrogerselectric.com STREET ADDRESS _ ._ - 2050 Marconi Drive Ste 200 M CITY,STATE,ZIP Alpharetta,GA 30005 FAX 305-301-2655 ❑OWNER ❑ OWNER BUILDER 11 OWNER AGENT M CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCIBTECT ❑ENGINEER ❑. DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# ��np Lin R Rogers 584017 C10 Applied For �lvj l COMPANYNAME`.in R Rogers Electrical Contractors,.Inc. E-MAM license@lrogerseleodc.com FAX 305-397-2655 STREET ADDRESS CITY,STATE,ZIP PHONE 2050 Marconi Drive Ste 200 Alpharetta,GA 30005 770-772-3487 ARCHITECUENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANYNANM F-MAIL - FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WI.DLAND ❑YESPROJECT IN ❑YES ISTHEBLDGAN ❑YES - BUILDING: IN COMMERCIAL URBAN INTERFACE AREA ❑NO FLOOD ZONE ❑NO EICBLERHOME? ❑.NO DESCRIPTION OF WORK - - Installing 3 receptacles for kitchen equipment TOTAL VALUATION: $2,500.00 By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property o er's behalf. I have read this application and the information I have provided is corr ct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relat"g to�buiil'd�ifi�g-cyons �Etron. uthorize representatives of Cupertino to enter the above-identified properly for inspection purposes. Signature of Applicant/Age ' / Date: 03/25/2016 SUPPLEMENTAL I ,/ TION REQUIRED -� - % �%' s ,"M MEPMiscApp 2011.doc revised 06121111 ./ Yt 4=a COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION- CUPERTINO k } /� W" A P f`[][�f1LJ t IRq+a2',iw sccla' Y vv<Fan natlGTAa SFE Ago � F This set of plans and specifications M JST be kept at the ®RUWE NR EC pN�(q CUUM RAS OFW ®, (q E TIE fVNSH LWUW iNSF�(�1)SECrgN OF BEW C HIFA W PRFPIJUTTN NR(N) 4Y job site during construction. It is unl wful to make any �;Igcnwf.....F,wcanWmRme nNaW„ ........... gee l rations on same, or to d .........................' changes orate ... __ ®)(q aACATXIlCBES W0. NOhn _."'_ irTT-r�r�, T 'T i ®..fq slmvwc m 1£RLwurzo sEE,� therefrom,without approval from th Buildin acral i m = dl-"II I;I F"1 f o �„ ro' W II. !I„. /)moi Ir./I'” 11/— i `�I ._IEJS R I I I /l I 1 I ``': (E) W EawiEfl 6nIG.9AnoN wr�m nEW1K The Stamping of this plan and specifications S .,NOT , I, I {k ®(q FlN�6 "--1 I I/ I/ I ., i t i ®(q uWU ranoro rrEwua. / �'i be held to permit or to be an approval of the iolation " I' _ f o(g �Nm�E i I•,;•, I II In,u A-._ 1 ©,BT10aTE(q L.'... of any p visions. any City Ordinz nce or Sta Law. I EXISTING L ©tq HWNxa 09ET L m sE ao { ---- f. 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