15050130CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10725 N DE ANZA BLVD
CONTRACTOR: ACCO ENGINEERED
PERMIT NO: 15050130
SYSTEMS
OWNER'S NAME: 10725 DE ANZA LLC
6265 SAN FERNANDO RD
DATE ISSUED: 05/21/2015
OWNER'S PHONE: 4088626637
GLENDALE, CA 91201
PHONE NO: (818)244-6571
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL
nn C
l ce
APPLE - REPLACE (E) BOILER, SAME LOCATION.
License Class Lic. #/
ContractorWO Date OZ /Ml.
I hereby affirm that I a 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: $89900
performance of the work for which this permit is issued.
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
APN Number: 32610065.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. 1 agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF 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 LLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
J
costs, and expenses which may accrue against said City in consequence of the
z /
granting of this permit. Additionally, the applicant understands and will compl
ed by: Date:
with all non -poi t source regul ti ns per the C ertino Municipal Code, Section
9.18.
D S 21
RE -ROOFS:
Signature Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, 1 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)
1, 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(x) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material, Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Muni i I Code, Chapter 9.12 and
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
the Health & Safety Code, Sections 5 05'533 n 25534.
/
Owner or authorized agent: Date:
permit is issued.
/
1 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, 1
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
1 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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
CUPERT#NO
GENERAL PERMIT APPLICATIONlD
o� MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 ` O MISC
(408) 777-3228 • FAX (408) 777-3333 • build ingAcupertino.orq \("�'
❑PLUMBING ®MECHANICAL [—]ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS
APN d
2 .a� ri
OWNERNAME40
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X109 – i(a "2.` (o (03
E-MAIL
ITREfT
ADD SSO
CITY, STATE, ZIP
c.,
FAX
CONTACT NAME
PHONE
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT
❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR t4AMELICENSE
NUMBER
LICENSE TYPE
BUS LIC b
ACCO rz,&
l �o ��
COMPANY NAM
E-MAIL
FAX
45, 0 —
STREET ADDRESS
CITY, STpj�. rE, ZIP �, '
S
44-
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC k
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY
PROJECT IN W ILDLAND ❑ YES
PROJECT IN
❑ YES
IS THE BLDG AN ❑ YES
BUILDING. ❑ COMMERCIAL
URBAN INTERFACE AREA ❑ NO
FLOOD ZONE
❑ NO
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
1 E Y`(1
TOTAL VALUATION:
66
i„
By my signature below,'! certify to each of the following: Idame property owner or authorized agent to acte"11?—property
owner'
ave re this
application and the information W^proved Is c�rrect.
read the Des _ iption of Work and veru a e o comply wit
�ha
ordinances and state laws ben> construJ�bUr author ite re rese tatives of Cupertino t�
p
deiuit
plif
-,e,
Signature of Applicant/Agenttm
�WYffP Date:
SUPPLEMENTAL
SUPPLEMENTAL, 14ORMATION REQUIRED
�.�
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'S'['ANDAI2D
TARGE '
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MEPMiscApp_201 1. doc revised 06/21/11
CITY OF CUPERTINO
FM -7 FEE ESTIMATOR - BUILDING DIVISION
imADDRESS:
10725 N DE ANZA BLVD
DATE: 05/21/2015
REVIEWED BY: MELISSA
UNITS
APN: 32610 065
BP#:
'VALUATION:
1$89,900
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
USE:
$179
PENTAMATION 1CMB7
PERMIT TYPE:
WORK
REPLACE E BOILER SAME LOCATION.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Boiler/Comp. <=50hp
1BBOILER(4)
1
#
$179
PME Unit Fee:
$179.00
PME Permit Fee:
$48.00
Cr jpgrncf im1 C C,o ,
Administrative Fee: (ADMIN
$45.00
Work Without Permit? O Yes G) No
$0.00
TOTALS:
Travel Documentation Fee: I TRA VDOC
$179.00
Strom Motion Fee: IBSEISMICO
Mech. Plan Check I 0.0 I hrs $0.00 " 'r��; l> /,/�.' £t r'1£'.(, £
Mech. Permit Fee: IMPERMIT Plw?rb
OtherMech. Insp. 1 0.0 1 hrs I $4$.00 ')tiro F'hw�[,, fwP
Nc£ /',/vr Che(",!(
I Ic r ln,vl 1'cc
i,icPoor if 1"ti,
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District_ etc )_ These foes are hated nn the nreliminary information availahle and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/11/3)
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee:
$179.00
PME Permit Fee:
$48.00
Cr jpgrncf im1 C C,o ,
Administrative Fee: (ADMIN
$45.00
Work Without Permit? O Yes G) No
$0.00
�£i£1.`r.l7ft 'If t�f�(Y1/11Y14? �'r'l'S:
Travel Documentation Fee: I TRA VDOC
$48.00
Strom Motion Fee: IBSEISMICO
$25.17
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$4.00
IJ fJ►"L'A
$349.17
$0.00 ilotl It F`EE:
$349.17
Revised: 05/07/2015