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13080086CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20525 MARIAM AVE CONTRACTOR: ICOM MECHANICAL INC PERMIT NO: 13080086 OWNER'S NAME: 20525 MARIAM DRIVE LP 477 BURKE ST DATE ISSUED: 08/27/2013 OWNER'S PHONE: 4089961010 SAN JOSE, CA 95112 PHONE NO: (408)792-2292 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL 11 License ClassC20 C34 6 Lic. # 22- APPLE- REMOVE (E) ROOFTOP EQUIPMENT AND � COM AklVC44V '5900- 2-r 011 Contractor � tirLDate REPLACE V6'ITII NEW 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: $200000 performance of the work for which this permit is issued. ave 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: 32656001.20525 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 WO IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 I) IT ISSUANCE ®I8 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 I A O LLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may ac a against said City in consequence of the granting of this pe Add 'Wally he applicant understands and will comply Pwneu b .. I� with all non -poi rce 2u io er the Cupertino Municipal Code, Section 9.18. �`�� ROOFS: Signature Date - All roofs shall be inspected prior to anyny roofing material being installed. If a roof is goo, 42L installed without first obtaining 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 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) 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. II 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) 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 equipmen or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Ar Ai Quality Management District II performance of the work for which this permit is issued. will maintain compliance with t pe no ipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sect' s 255 5 , an 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent Date: Ar�Lj t 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 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 CUPERI-INQ GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT e BUILDING DIVISION V 10300 TORRE AVENUE e CUPERTINO, CA 95014-3255 (408) 777-3228 o FAX (408) 777-3333 e building(a?cupertino.org PLUMBING MECHANICAL ❑ ELECTRICAI ❑ MISCELLANEOUS PROJECT ADDRESS2f%I �� 7APN # Z(o 00( OWNERNAME� �� d E-MAIL STREET ADDRESS jr t L_JW /� CITY, STATE,Z[P &*_jj rj 0 pow®®®® A�w' FAX CONTACT NAME t PHONE�n ��®� ( E -M G I Loi CJMP/'LC STREET ADDRESS A /� � !�,❑ CITY, STATE, Z . ` J6� 1 P(2— VT 6❑ F o� 2-4 A If f(.81 a❑ ®TENANT ❑ OWNER ❑ OWNER -BUILDER OWNER AGENT )(CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ENGINEER ❑ DEVVELO(PEER CONTRACTOR NAME_ \ ts, LICENSE NUMB (� y CENSE QE BUS. #, k COMPANY NAME W"L E-MAIL STREET ADDRESS ^ CITY, STAT ZI ��F A 6 PTONFg. 7f2 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUTS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMILYPROJECT BUILDING: ❑ COMMERCIAL 7 IN W ILDLAND ❑ YESIF URBAN INTERFACE AREA ❑ NOOOD ROJECT IN El YES ZONE ❑ NO IS THE BLDG AN ❑YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK kvrr 0bmf Ne.4 (E"tk6i,,T OF l t10,& e L t: )C� TOTAL VALUATION: RECEIVED By my signature below, [certify toe eofthelol ng: application and the information I v pecl. ordinances and state laws relati bution. Signature ofAppIicant/Agent I am the property owner or authorized agent to act on th property owner's behalf. 1 have read this I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local 1 authorize representatives ofCupertino to enter the above -identified property for inspection purposes. Date/� e a C61- SUP LF, NTAL INFORMATION REQUIRED OFFICE USE ONLY W ❑ OVER-THE-COUNTER a ❑ EXPRESS U U W ❑ STANDARD U U < ❑ LARGE a ❑ MA.IOR MEPMiscApp 2011.doc revised 06/21/11 CITY OF CUPERTINO FM -0 FEE ESTIMATOR - BUILDING DIVISION imADDRESS: 20525 Mariani ave DATE: 08/12/2013 REVIEWED BY: Mendez 1,Iech. Perwid Fee: APN: BP#: 1V08l910616 *VALUATION: 1$200,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: Plurnb. lisp. Fee: PENTAMATION 1 GENCOM PERMIT TYPE: Q WORK Apple- remove rooftop equipment and replace with new SCOPE NOTE: This estimate does not include fees due to other Departments (Ge. Planning, Public !'forks, Fire, Sanitary Sewer District, School District, eta). These fees are based on the preliminary information available and are onlv an estimate- Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Ef. 7/1112) Xlech. Plan Check Phunb. Plao Cheek i I Elee. Plan Check -=�: 1,Iech. Perwid Fee: Plumb. Permit Fee: Elec. Permit Fee: Other A9ech. insp.Li Other Plumb Insp. Other Elec, Insp. El Arlech. lnsp. Fere Plurnb. lisp. Fee: Elec. Insp, Fee: NOTE: This estimate does not include fees due to other Departments (Ge. Planning, Public !'forks, Fire, Sanitary Sewer District, School District, eta). These fees are based on the preliminary information available and are onlv an estimate- Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 Ef. 7/1112) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes 0 No $0.00 3 hours $417.00 Plan Check, Hourly 1STPLNCK Suppl. PC Fee: (j) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes (E) No $0.00 Suppl. Insp. Fee:Q Reg. 0 OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Contraction :Ta:v: Ll ildminlstrative Tee'.- 0 E) Work Without Permit? 0 Yes (.j No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure E) A Travel Documentation Tees: Strong Motion Fee: 1BSEISMICo $42.00 5.0 hrs $695.00 Inspections ISTINSP Inspection, Hourly Bldg_Stds Commission Fee: 1BCBSC $8.00 SUBTOTALS: $50.00 $1,112.00 TOTAL FEE: $1,162.00 Pp7pp, CUIP[i:6@TIMO CONTRACTOR / SUBCONTRACTOR LIST Bultding Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: X "mA &C PERMIT # D8'®0 9-& OWNER'S NAME: WkAF INLS PHONE # 77 7, g94`2— GENERAL CONTRACTOR: j L&zAorb �jt BUSINESS LICENSE # o -q ADDRESS: CITY/ZIPCODE: "� Q Q 2�— *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING ]FINAL OR ]FINAL OCCUPA IN C ON(S) WILL BE SCHEDULED UN'T'IL THE GENERAL CON'T'RAC'T'OR AND ALL SUIS T S HAVE OBTAINED A CITY OF CUP ERTINO BUSINESS LICENSE. I am not using any subcontractors: 0 On i re Date Please check applicable subcontractors and complete the following information.- SUBCONTRACTOR nfforllIll]lation: Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting n.1 Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date