10110031I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 20380 TOWN CENTER LN CONTRACTOR: PARAGON PERMIT NO: 10110031
MECHANICAL, INC.
OWNER'S NAME: WOODMONT REAL ESTATE-ELLEN LODGE 2460 DE LA CRUZ BLVD DATE ISSUED: 12/20/2010
OWNER'S PHONE: 4089730783 SANTA CALARA, CA 95050 PHONE NO: (408)727-7303
E LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
License Class6 �d pC ',ic. 4
Contractor ' � ,
that 1 am li nsed un er 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.
1 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.
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
12 — ,2d •112
❑ 6' OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
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 sale (Sec.7044,
Business & Professions Code)
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:
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.
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.
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
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.
FOR ENTIRE COMPLEX @ ROOTOP EQUIPMENT WELL -
LIKE
KIND REPLACEMENT OF 500K BOILER
Sq. Ft Floor Area: I Valuation: $35000
APN Number: 36940059.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued _-- Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being instal led. 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 "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I 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 1
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Secti
LENDING AGENCY
1 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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Signature Date
IC) 1 �\
CITY OF CUPERTINO
FM-1, FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20380 town center lane
DATE: 11/04/2010
REVIEWED BY:
APN:
BP#:
'VALUATION: 1$35,000
PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: Commercial Building
Tl)r:;1,
ll O(?l; .!r';F:;i:
PENTAMATION
PERMIT TYPE: 1CM138
WORK
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY
UNITS
BP FEES
Boiler/Comp. <=15hp
1BBOILER(2)
1
#
$116
TOTALS:
$116.00
Mech. Plan Check 2.0 hrs $252.00
Phimb. Plun C'hc ck
F/(,, Plan G°heck
IMECPLNC Mech. Permit Fee: IMPERMIT
F'Irrmb. F'e r,;,i F e:
! (ec. Pc;rn,i Fee:
Other Mech. Insp. 1.0 �rs$42.00
0/,,h . r;l,,;,b ,;,,;
Odic?, ISlcr. Insp. ET
Mech. Insp. Fee: IMECHINSP $126.00
Phaub, i„r.,,. l car:
Ele, b,sp. F, c:
NOTE: These -fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 09-051 G . 7/I/I01
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
suppl. PC Fee
PME Plan Check:
$252.00
Permit .Fee.
supp/.Insp Fee
PME Unit Fee:
$116.00
PME Permit Fee:
$168.00
Construction .Tax
Acoustical Review Fee. -
Work Without Permit? 0 Yes 0 No
$0.00
Mannino Fees:
i
Travel Documentation Fee: ITRAVDOC
$42.00
Strong Motion Fee: IBSEISMICO
$7.35
Select an Administrative Item
Bldi; Stds Commission Fee: IBCBSC
$2.00
SUBTOTALS:
1 $587.351
$0.00 TOTAL FEE:
$587.35
Revised: 10/1712010