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14100108rI CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20400 MARIANI AVE CONTRACTOR: ICOM MECHANICAL INC PERMIT NO: 14100108 OWNER'S NAME: MISSION WEST PROPERTIES 477 BURKE ST DATE ISSUED: 10/20/2014 OWNER'S PHONE: 4087250700 SAN JOSE, CA 95112 PHONE NO: (408)792-2292 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL �J c3% APPLE - INSTALL (N) SINK IN ROOM A150 License ClassO '�Q JLIC. # y Pf� 1/r/�)7Y, Contractorl,,at'j /SGL Date .20 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: 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 Sq. Ft Floor Area: Valuation: $5000 erformance 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 APN Number: 31622018.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS IT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses wh' ay accrue against said City in consequence of the �O Z granting of this pe ditionally, licant understands and will co with all non -point ur regulat' s per the upertino Municipal Code, 9.18. Signature Dat lV• RE -ROOFS: All roofs s all be ins prior to any roofing material being installed. If a roof is installed 'itobtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a ho store r handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I us ment es which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by t B rea r Q li Management District I performance of the work for which this permit is issued. will maintain compliance with up tin icipal ode, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sec ns 255 nd 2 534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent Dat 4 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CUPERTINO �D GENERAL PERMIT APPLICATION o MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 t �\ (408) 777-3228 • FAX (408) 777-3333 • buildingOcuaertino.org `' \ MISC PLUMBING ❑ MECHANICAL FJELECTRICAL MISCELLANEOUS PROJECT ADDRESS ZDL4O APN # i- ^ ,., LE OWNER N � �, V l/V'�J �D -TONE -MAI — / ST Ef.�DOD �� I ` J`_ vv CITY TAT ' ` r /� A 'i� OI 1`1 l►T') l FAX .--` CONTACT NAME �" ►'` t c c PH 2 2 MAIL e �I Sunc.�-r+(H c_ c• r✓1 STREET ADDRESSu �� Cl:' S ATE, ZiPsc- e^ ^ `1 L❑ F Dk 11 OWNER 11OWNER-BUILDER11OWNERAGENT CONTRACTOR 11 CONTRACTOR AGENT ARCHITECT ENGINEER ❑ DEVELOPER ❑ TENAN7 CONTRACTOR NAME 'L LIC C BUS. L #�(:fo O COMPANY NAME (^ _yq :I C / !� - I �1 E-MAIL F �� STREET ADDRESS ^ , ST TE, Z[ � �� / P �� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAB, FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY BUILDING: ❑ COMMERCIAL PROJECT M WILDLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ ) FS EICHLER HOME? ❑ h0 DESCRIPTION OF WORK S / 1014— ZOOMO TOTAL VALUATION: `''V RECEIV By my signature below, I certify to each of lo III• application and the information I have p is Corr t ordinances and state laws relating to b in co Signature of Applicant/Agent: m the property owner or authorize t to ac c pr owne ' e I ave re ave read the Description of Work and verify it is accurate. I agre c y with all applicable 1oc31 authorize representatives of Cupertino to enter the above-ident roperty for inspection purposes. Date:c2LC SbPPLIVetArKFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER F' U ❑ EXPRESS U ❑ STANDARD U U z_ ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doc revised 06121/11 FF �� CITY OF CUPERTINO . o FEE ESTIMATOR - BUILDING DIVISION APPLIANCE / EQUIP TYPE 20400 MARIAM AVE DATE: 10/20/2014 REVIEWED BY: MELISSA jigADDRESS: APN: 316 22 018 BP#: / y��Q�Q *VALUATION: 1$5,000 'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building USE: # PENTAMATION 1 CPFIX PERMIT TYPE: A WORK APPLE - INSTALL N HAND SINK IN ROOM A150 SCOPE Fac APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 hrs $0.00 QTY UNITS BP FEES Fixture or Trap 1BPFIXTURE 1 # $10 Fac PME Unit Fee: $10.00 PME Permit Fee: $48.00 -T-T Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (F) No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $10.00 Strong Motion Fee: 1BSEISMICO NOTE: This estimate does not include fees due to other Departments (Le. 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'l info. FEE ITEMS (Fee Resolution 11-053 EfT 7/1 `13) FEE Plumb. Plan Check 0.0 hrs $0.00 MISC ITEMS Plumb. Permit Fee: 1PPERMIT 11,/,t. 1't. f L, ,, Other Plumb Insp. E]hrsl $48.00Lj Pjzo;it,. hop, Vet - $0.00 NOTE: This estimate does not include fees due to other Departments (Le. 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'l info. FEE ITEMS (Fee Resolution 11-053 EfT 7/1 `13) FEE QTY/FEE MISC ITEMS 11,/,t. 1't. f L, ,, PME Plan Check: $0.00 Fac PME Unit Fee: $10.00 PME Permit Fee: $48.00 -T-T Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (F) No $0.00 Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: 1BSEISMICO $1.40 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $153.40 $0.00 TOTAL FEE: $153.40 Revised: 08/20/2014