B-2016-2345CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
19620 STEVENS CREEK BLVD CUPERTINO, CA 95014-2465 (369 06 012)
CONTRACTORe PERMIT NO: B-2016-2345
BUILDING SERVICES
SYSTEM
INCORPORATED
CONCORD, CA 94520
OWNER'S NAME: EVERSIDNE VI, LP
DATE ISSUED: 07/19/2016
I OWNER'S PHONE: 408-343-1088 I (PHONE NO: (925) 688-1234
LICENSED CONTRACTOR'S DECLARATION
License Class B Lic. #870303
Contractor BUILDING SERVICES /SYSTEM MAINTENANCE IN ORPORATED
Date 01/31/2018
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:
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.
2. I 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,
permit is issued.
APPLICANT CERTIFICATION
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 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 L /j .Date 07/19/2016
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. 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)
2. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
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.
2. I 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
permit is issued.
3. 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 become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
APPLICANT CERTIFICATION
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 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.
BUILDING PERMIT INFO:
X BLDG X_ ELECTS _ PLUMB
_ MECH _ RESIDENTIAL X COMMERCIAL
JOB DESCRIPTION:
2 (N) EV CHARGING STATIONS (40 AMP EACH) - PARKING LOT; (N)
200 AMP SUB -PANEL
Sq. Ft Floor Area I Valuation: $25000,00
APN Number: Occupancy Type:
369 06 012
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by PAUL O'SULLIVAN
Date: 07/19/2016
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,
Signature of Applicant:
Date: 07/19/2016
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Secdons`25505, 25533, and 25534. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, -Sections 25505-26&M. and 25534.
Owner or authorized agent:
Date: 07/19/2016
CONSTRUCTION LENDE'qG AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION'
10300 TO'RRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 building(g)cupertino.Orcl
EJ ,
PROJECT ADDRESS 19620 Stevens Creek Blvd
APN# 369-06-012
OWNERNAMTrCR Management LLC -Mark Battstini
I�
PHON
E-
M attistini@kcrdevelopment.com
STREET ADDRESS19620 Stevens Creek Blvd
CITY, STATE, ZIP
Cupertino, CA 95014
FAX
CONTACT NAME
Felix Jaralba- Volta
PHONE
384-6537
E-MAIL
E-MAIL felix@voltacharging.com
STREET ADDRESS
155 DeHaro St
CITY, STATE, ZIP
San Francisco, CA 94103
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑. TENANT
CONTRACTOR NAMELICENSE
7lJ T faA.S
NUMBER
3
LICENSE TYPE
g
BUS. LIC # /1101
oil9-
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS y
CITY, STATE, ZIP
PRONE y
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #'
Jason Dubets
COMPANY NAME
Byers Engineering Company
E-MAIL 'aSOn.dubets b erS.com'
J @ Y
FAX
STREET ADDRESS
4780 Chabot Drive, Suite 104
CITY, STATE, ZIP
Pleasanton, CA 94588
PHONE
925.398.6012
USE OF ❑ SFD Or Duplex ❑ Multi -Family
PROJECT IN WILDLAND
PROJECT IN
STRUCTURE: X1 COmmerCial
URBAN INTERFACE AREA ' ❑ Yes JN NO
FLOOD ZONE ❑ Yes Ell. NO
❑ SOLAR PANELS
ELECTRIC VEHICLE CHARGING STATION
FO SOLAR WATER HEATING
❑ OTHER:
FOR SOLAR PANELS. NUMBER OF PANELS/UNITS: KILOWATTS (COMMERCIAL ONLY):
TOTAL VALUATION:' � - -"
DESCRIPTION OF WORK
Prepare and install 2 new charging station Kiosks with 2 new charging bollards. Install 2 new concrete
equipment pads. Install new electrical conduit from point of connection to (N) Kiosks. Install new sub panel.
pw Amec
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 o ner's behalf�I have dead this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating toni"lding cons tion. I tho ' e representatives of Cupertino to enter the abov -ide property for inspection purposes.
`'fled
Signature of Applicant/Agent: Date:
PLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
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EXPRESS
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❑ STANDARD .
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Il LARGE
MAJOR
PVApp 2011.doc revised 03116111