06050197CY OF CUPEKI lNU
BUILI„NG DIVISION PERMIT
BUILDING ADDRESS:
21111 STEVENS CREEK
OWNER'S NAME:
CITY OF CUPERTINO
NE:
ARCHITECT/ENGINEER:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
,n full force and effect.
License Class Lle- #
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ 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
and Professions Code: The Contractor's License Law docs not apply to an miner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. It,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
as owner of the property, am exclusively contracting with licensed contractors to
1uct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt B & P C for this mason
Owner .' 'Date
WORKER'S OMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
L3 i hr.ve and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, 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 required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
My Workees Compensation Insurance carrier and Policy number arc:
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artier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars ($ 100)
x less.)
l certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any t to become subject to the Workcrs' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
building consuuction, and hereby authorize representatives of this city to enter upon thc
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 in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REG
Signature off' pplicanUContractorJ/ Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? — /
❑Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements w riot to issuan -"*-Ccnificatc of Occu ancy.
Owner or authorized agent �/ Date
PERMIT NO.0 6 0-50197
PERMrr ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
Job Description
REPLACE 10 TON HVAC/SPORTS CENTER -CITY JOB
CONTRACTOR: WKW MECHANICAL CONTRACTORS, INC
Sq. Ft. Floor Area
NN Number
329022.00
rr
Issued by:
Re -roofs
Type of Roof
Required Inspections
1
Type
Date .5-1
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
All roof coverings to be Class "B" or better
05/23/2006 07:48 4087791168 WKW MECHANICAL PAGE 01/03
% Me,ch IniGa[Cont'=t ,rs, Inc.
550 Mon" Rd., Unit D
Ifo wan Hi�f, CA 95037
Ph(408)779-9779 FaX (408) 779-1168
FAX TRA,NSMMA>L SHEET
James Davis From: Sam Lopez
i an : City of Cu ertino Date: 5/23/2006
#: 408-777-3399 Fax #: 408-779-1168
ie #: 408-777-3271 Phone #: 408-7799779
Sports Center e-mail: sl _*wk%miech nica[.com
No. of pages, including cover sheet: 3
If this transmission is incomplete, please call 408-779-9779
Comments:
Evidence of insurance and copy of contractor's license follow.
05123/2006 07:48 4087791168 WKW MECHANICAL
,aCQWL CERTIFICATE OF LIABILITY INSURANCE �
p eifeR THIS CERTIFICAT� IS ISSUED AS A IIL
Tsi#Q],d E Ca TrtL!' SaTiL_asS, Iris ONLY AND CONFERS NO RIGHTS UPC
Licenae #0627712 HOLDER, THIS CERTIFICATE DOES N(
P" WAst Julian St., Suite 403 ALTER TK COVERAGE AFFORDED B'
JO$e CA 95110
Dons: +405977-1213 raa:1409-977-1273 INSURERS AFFORDING COVERAGE
INSURED
INSURERA: St. Paul/Travelers
WW Mmc)l anical COntraQtar INSURER H;
Harry Kick INSURER C;
550 monterey Rd
Dorgan Hill CA 95037 INSURER D:
PAGE 02/03
DATE 0 A MONYYY)
05/13/05
Tf;R OF INFORMATION
THE CERTIFICATE
AMEND, EXTEND OR
r"E POLICIES BELOW,
THE POLICIES OF INSURANCE LISTED BELOW HAW 8£EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD mr.ATEp, NOTWITHSTANDING
ANY REWREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED MEREW IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANI] CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEAN REDUCBP EY PAID CLAIMS.
R TYPE OF INSURANCE POLICY NUMBER TIEM
A
A
GENERAL LIAOUrY
]� COMME=RCIAL GENERAL LIABILITY DTEC07855A043TTL05
CLAIMS MADE [jEl OCCUR
GE_WL AGGREGATE LIMIT APPLIES PER!
POLICY FX7 MT E71 LOC
AUTOMOMLE LIAMITY
X ANY AUTO DT8107135SA,043T3=5
ALL OWNED AUTOS
SCHEDULED AUTOS
X HIRED AUTos
X NON -OWNED AUTOS
GARA09 UABILITY
ANY AUTO
EKCIR"A {ABRELLA LIABItJTY
A X OCCUR CLAIMSMADE DTSb=P365K5793
RDEDUCTIBLE
X RETE-NTM $10000
YYLSRKMB 00111FBN9ATION AND
A IMPLOYLkV UA UrY
ANY PROPRIETORIPARTNER/EXECUTNE US365K74SATx1,05
OFFICER/MEMBER EXCLUDED?
4+tAL PROVISION* pelew
OTHER
09/11./05
09/11/05
09/11/05
NAIL 0
A
LIMITS
EACH OCCURRENCE
$1000000
09/11/06
PREMISES c=jrence
s300000
MED EXP (Arty ane penes)
$5000
PERSONAL A ADV INJURY
S 1.000_000
_GENE AGGREGATE GGREGATE
$ 2000000
PRODUCTS •COMP/OP AGO
$2000000
Em Ban.
itA/ a $► w
09111106
COMBINED SINGLE LIMIT
IEe e�i�Iwn)
$ 1000000
BODILY IMIURY
(Per penal)
$
BODILY iNj Ry
$
(Per WCldenl)
PROPMWY DAMAGE
(Per eeeldOM)
AUTO ONLY - EA ACCIDENT
S
OTHER THAN EA ACC
S
AUTO ONLY; AGG
EACH OCCURRENCE
$ 5000000
09/11/06
AGGREGATE
$ 5000000
Is
�_
>3
10/01/05 10/01/06 E,I„EAGHACCI ACCIDENT _ $1000000
E.L. DISEASE . EA r=MpLOyEE 3 1000000
E,L., DISEASE • POLICY LIMfr 5 1000000
IgalumFTIGN OF OP4FiATIONS i LMATIONS 1 V£MICL/ "CLUSIONB ADDED BY E1NQ0MGMENT! SPEE
:ertifinats is issued as I1videnae Of in$t[Zanae Only,
:ERTIFICATE
XV11DE-1 SHOULD ANY OF THE ABOVE AEBCRIBED POLIOES BE CANCELLED BEFORE THE 0WIRATIC
13ATS THEAEPF, THE t$SUM, INSURER WILL I!NDQAVOR TO MAR 30 LAYS WRITTEN
Evidence of insurance) NOTICE: TO tHE CERTIFICATE HOLDER MAMBO TOTHE LEFT, BUT FAILURE TO 00 30 SHALL
IMPOSE NO OBLIGATION OR LJABtt,ITY OF ANY KIND UPON THE IN*URHR, ITS AGMTS OR
�nIA1T� .ti
1988
05/23/2006 07:48 4087791168 WKW MECHANICAL PAGE 03/03
3 26- 29- oZZ
,%at* Of California
CONTRACTMS STATE LICENSE BOAIM
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05/31/2007
C4 nelna ry y o fAM4r did Rt i
CITY OF CUPERTINO
s FURNACE/AC
;UPE TINO PERMIT APPLICATION FORM
APN #
32_b- 2c
o2--7—
Building
z-ZBuilding Address: v'e n" S C r e ,r, l
Owner's Name: C
try
Contractor: W K W
Contact:
Building Permit Info:
Bldg ❑
Job Description:
Residential ❑
f Gv �'&-r,f [Aa
Phone:
Phone:
r-
'77-7
Elect N
Commercial
aQc�iqv
Date `2j _0
Phone #: ?77- 32 6 �
License #: ?b L�
' 77
Cupertino Business License #:
_3272
Plumb $S Mech (LJ
1 T vk�
For Residential Installations:
Attic ❑ 1' floor ❑ 2nd floor ❑
Adhere to min set back requirement ❑
For Commercial Installations:
Additional weight (structural calcs)
Replacement same weight 0' ❑
Structural Calculations required for new installation
New installation Planning App roval Required ❑
Cost of Project: Type Cif , sA S9 tion:
Strapped ❑ On Platform ❑ Bonded
New Location ❑ Replacement a
Qty. if
7q&
Fee ID
BREMRECEPT
BSEISMICRE
BSEISMICOM
EPERMITFEE
MPERMITFEE
PPERMITFEE
BPERMFEE
J=jPLANCHK
B1PGAS
BUSLIC
group:
Sq.Ft. Floor Area:
Fee Description
Fee Grou
Ener
BUILDING
Furnace
MECHANICAL
4
A/C Unit > 10,000 cfin
MECHANICAL
A/C Units <= 10, 000 cfm
MECHANICAL
Rec tl, Switch & Outlets
Seismic Fee Res
JELECTRICAL
UILDING
Seismic Commercial
UILIDNG
Elec Permit Issuance
ELECTRICAL
Mech Permit Issuance
MECHANICAL
Plumbing Permit Issue
PLUMBING
Bld Permit Fees
BUILDING
Plan Check Fee
BUILDING
Gas Piping System Fee
PLUMBING
Business License
BUILDING