15100163CITY OF CUPERTINO BUILDING
PERMIT
BUILDING ADDRESS: 10520 S DE ANZA BLVD
CONTRACTOR:
PERMIT NO: 15100163
I
OWNER'S NAME: HARMAN-MANAGERS INVESTMENT INC
DATE ISSUED: 10/20/2015
OWNER'S PHONE: 9092433533
PHONE NO:
® LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPFON:
RESIDENTIAL [ICOMMERCIAL F1DISCONNECTINCIRCUITS
FROM UNDERGROUND TO
License ClassLic. #
OVERHEAD AND
ADDING (7) CIRCUITS.
+
Contractor%^rte/ �� Date
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:
Sq. Ft Floor Area
Valuation: $1500
�. 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
APN Number: 36939017.00
Occupancy Type:
performance of the work for which this permit is issued.
� 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
permit is issued.
PERMIT
EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION
WITHI
180 DAYS OF PERMIT ISSUANCE OR
I certify that I have read this application and state that the above information is
180 DAYS
FROM LAST CALLED INSPECTION.
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
Issued by:
d
- Date: / • -
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses whi may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with
all non-point ice r lati ns per the Cu o Municipal Code, Section 9.18.
RE-ROOFS:
n
Signature Date �(/
All roofs shall bei
installed without fi
spected prior to any roofing material being installed. If a roof is
st obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Appli
ant: Date:
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
ALL ROOF
COVERINGS TO BE CLASS "A" OR BETTER
the following two reasons:
�. 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
HAZARDOUS MATERIALS DISCLOSURE
sale (Sec.7044, Business & Professions Code)
I have read the ho
zardous materials requirements under Chapter 6.95 of the
2. 1, as owner of the property, am exclusively contracting with licensed contractors to
California Health
& Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
construct the project (See.7044, Business & Professions Code).
compliance with the
Cupertino Municipal Code, Chapter 9,12 and the Health &
Safety Code, Sect
on 25532(a) should I store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations:
Additionally, should
I use equipment or devices which emit hazardous air
t. I have and will maintain a Certificate of Consent to self-insure for Worker's
contaminants as d
efined by the Bay Area Air Quality Management District I will
Compensation, as provided for by Section 3700 of the Labor Code, for the
maintain compliarice
with the Cupertino Municipal Code, Chapter 9.12 and the
performance of the work for which this permit is issued.
Health & Safety Code,
Sections 25505, 25533, and 25534.
2. 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
O or u ori
ed agent:
✓ Date:. ' o/��Z 5
permit is issued.
3. I certify that in the performance of the work for which this permit is issued, I shall
CONSTRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the Worker's
I hereby affirm r
there is a construction lending agency for the performance of work's
Compensation laws of California. If, after making this certificate of exemption, I
for which this peem
it is issued. (Sec. 3097, Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code, I
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
revoked.
Lender's Address
APPLICANT CERTIFICATION
ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is
I understand my pl
s shall be used as public records.
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
Licensed Professi
nal
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 may accrue against said City in consequence of the
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.
Signature Date
;4)
CITY OF CUPERT
FEE ESTIMATOR — BUILDI:
ADDRESS: 10520 S De Anza Blvd DATE: 1
APN: BP#:
PERMIT TYPE: Electrical Permit PLAN CHECK T
USE
-ICommercial Building
WORK I Disconnecting (9) circuits from underground to
SCOPE
O
T DIVISION
0/2015 REVIEWED BY: Sean
,,VALUATION: 1$1,500
"L: Alteration / Addition / Repair
PENTAMATION
Pri D1VffT TVDr. 1 CEAP10
APPLIANCE / EQUIP TYPE FEE ID 9TY UNITS BP FEES
Recep/Switch/Outlets -/'1 BREMRECEP 17 # $48
TOTALS: (,` $48.00
11 ch, Plan Check I" imb. Plan (-`heck Elec. Plan Check 0.0 hrs $0.00
Wech. /'ennit Fee: I'/rrmb, .F'ettaaa Fee: Elec. Permit Fee:-EPERMIT
flierllech..hlsP• Other I'dasmbImp. Other Elec. Insp. 1.0 hrs L$48.00
Wech. Insn. I` c: P{;, rtr t,,c<;,Fee: Elec. Insp. Fee: IELECINSP $143.00
NOTE: This estimate does not include fees due to other Departments (i.e. PlanninPublic Works, Fire, Sanitary Sewer District, School
DLSPrLCt. Qte J. TIf.O.CP FOO.0 /1P0 RQCO/I /!N tLIO 71Y0%)LHIHOYV 7HF/�YYH/1/)nl9 nvnilnhln n»d ro n»hf nti actiivrnfa !'n»tort tho nonf for ndilti'1 i»fon
FEE ITEMS (Fee Resolution 11-053 Elf.' 7/U13FEE
QTY/FE
MISC ITEMS
Plan Check .Fee:
A
Smnnl. PC Fee
F
PME Plan Check:
$0.00
laE'i'BT71/ .l' ee:
Suppl. /i''sp Fee
PME Unit Fee:
$48.00
PME Permit Fee:
$191.00
('t1nsir uct ion Tax:
Administrative Fee: mDMIN
$45.00
Work Without Permit? O Yes 0 No
$0.00
:rl�-criac��r�.l'lc�niiriz� .F'ee,�•:
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee: IBSEISMICO
$0.50
Select an Administrative Item
f®
Blde- Stds Commission Fee: IBCBSC
$1.00
SCAT -0 'ALS;>;
$333.50
$0.)01-11T(3 `ASF
$333.50
Revised: 10/01/2015
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CUPERT�NO
GENERAL PERMIT APPLICATION M E P50'
COMMUNITY DEVELCPMENT DEPARTMENT • BUILDING DIVISION
10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • 'buildino(d)cuoertino.org
❑ PLU]\/'3RvG ❑ 1 I-CHA?\ZCAL ELECTRICAL ❑ hr, ISCELLAYlEOUS
PROirCT.SDDP,E�S�n Own av "N'(J
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By my signature!be1 -,, I certify to each Df the following: I an the property ori ner or auLhorized aunt to act on the property owner's behalf. I have read th s
application and the Lnfornation I have prm i - ed is cor,ect. I have read the Description of Work and verify it is accurate. I ap ce to comply with all applicable local
ordinances and sL:e laws relztirg uild e con traction. I authorize representatives of Cupertino to enter the zbo e -identified prop- ty for inspection par ores.
Signature ofA.pplicazt/Agent: �C Date:
SU-PPLEMENTAL LNTFORMATION REQUIRED
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1t/EPA/SCApp_2011. do revised 05/_71/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
1AADDRESS:
10520 S De Anza Blvd
DATE: 10/20/2015
REVIEWED BY: Sean
UNITS
APN:
BP#:
*VALUATION: 1$1,500
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration /Addition /Repair
PRIMARY Commercial Building
USE:
#
PENTAMATION 10EAP10
PERMIT TYPE:
WORK
Disconnecting 9 circuits from underground to overhead and adding 7 circuits.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Elec. Permit Fee:-.1EPERMIT
Recep/Switch/Outlets
-11, BREMRECEP
Elec. Insp. 1.0 hrs$48.00
7
#
$48
PME Unit Fee';
$48.00
PME Permit Fee:
$191.00
Administrative Fee: ]ADMIN
✓ $45.00
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICO
NOTE. his estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS i,(Fee Resolution 11-053 E : 7/1/13)
FEE
QTY/FEE
Elec. Plan Check 0.0 hrs $0.00
Elec. Permit Fee:-.1EPERMIT
LiOther
Elec. Insp. 1.0 hrs$48.00
PME Plan Check:
Elec. Insp. Fee: IELECINSP $143.00
NOTE. his estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS i,(Fee Resolution 11-053 E : 7/1/13)
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee';
$48.00
PME Permit Fee:
$191.00
Administrative Fee: ]ADMIN
✓ $45.00
Work Without Permit? 0 Yes 0 No
$0.00
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICO
$0.50
Select an Administrative Item
Bldg Stds Con mission Fee: IBCBSC
$1.00
SUBTOTALS;
$333.50
$0.00 TOTAL FEE:1
$333.50
Revised: 10/01/2015
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