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12090198CffTY OF CU P]ERUND BUIDLWNG P E]EBMffT BUILDING ADDRESS: 10381 BANDLEY DR CONTRACTOR: WESTERN ALLIED CORP PERMIT NO: 12090198 OWNER'S NAME: LV CUPERTINO LLC 1180 O'BRIEN DR DATE ISSUED: 11/15/2012 OWNER'S PHONE: 4089551416 MENLO PARK, CA 94025 PHONE NO: (650)326-0750 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License ClassCao . Lic. # TO-6 79 Z APPLE - REPLACE 14 ROOFTOP MECHANICAL UNITS, REMOVE 2 UNITS Contractor Date 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: $300000 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 APN Number: 32633079.000 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is ]P]Ei j MffT Ei X PER S IF WORK IIS NOT STARTED correct. 1 agree to comply with all city and county ordinances and state laws relating ��N �® �� ®� �� ®� 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 SDA ROM (LAST CALLED IDBS? ECTffON. 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 �. granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non-point so urc ations per the Cupertino Municipal Code, Section 9.18. . RE-ROOFS: Signature Date ,!f2f -If—?a-- 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. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that 1 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). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. ➢ 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 ➢ 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 ➢ performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorizedage Date: 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, 1 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 1 certify that 1 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 I D CUPERTINO COMMUNITY DEVELOPMENT DEPARTMENT ^ BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 ^ FAX (408) 777-3333 ^ building(-)cupertino.org 1-2 Oq 0) 9 e ❑ PLUMBING &aCHANICAL „-_(ry U ELECTRICAL ❑ MISCELLANEOUS PROJECT ADD SS V� APN # --35, 35 0 -7 OWNER NAME v r PHONE ` E-MAIL 1 L 955 _ 6 416 STREET ADD SS R -j-, S�t�e O CITY, STATE, ZIP °i� �� FAX CONTACT NAME PI ®1 -O SQ MAIL 0 s 40 STR.EfT j&SS �v� CITY, STATE, ZIP �� c FAX C)34 -�0 ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRA OR NAME G� ENS NU E LICENSE TYPE C20 clf-S BUS. LIC # OM ANY NAME ► E -M ^ �� X �^ A STREET RE S _ ^ CITY, STATE, ZIP6A P� A2_(qb ®� ®n Q iq 2.So- ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES BUILDING: jP�&MMERC1,4L URBAN INTERFACE AREA AE�4NO FLOOD ZONE IQ EICHLER HOME? 50 DESCRIPTION OF WORK ^ �9 (.a ve TOTAL VALUATION:3o O O O Q RECEIVED BY: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building truction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMEN INFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER ca a E' ❑ RESS x U W STANDARD U ❑ LARGE a, ❑ NIAJOR MEPMiscApp_2011.doc revised 06/21/11 i/"�ArFPQI A't Tn ir'1TFTTM'97V'brMTrT\TAT APPLIANCE / EQUIP TYPE H %-or 'k— UII 1LHO11ll1V\U FEE ESTIMATOR - BUILDING DIVIRON FjV..Il11 TADDRESS: 10381 Bandley DATE: 09/24/2012 REVIEWEDBY: jsg UNITS PN: BP#: 17ALUATION: 1$300,000 *PERMIT TYPE: Mechanical Permit PIAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building # PENTAMATION FIIRN/AC USE: Furnace, Forced -Air PERMIT TYPE: Suppl. Insp Fee 14 WORK Replace. 14 rooftop units remove 2 units. SCOPE PME Unit Fee: APPLIANCE / EQUIP TYPE FEE IIID Phunb. Plan Check QTY UNITS BP FEES Elec. Permit Fee: A/C Units (>10K cfm) f (n c' Other Elec. Insp. C 14 # $1,862 Furnace, Forced -Air 1MFR=<100 Suppl. Insp Fee 14 # $1,862 PME Unit Fee: $3,724.00 PME Permit Fee: $45.00 Consiruction .Tax: Administrative Fee: (ADMIN $42.00 Work Without Permit? 0 Yes E) No $0.00 TOTALS: a Travel Documentation Fee: ITRA VDOC $3,724.00 Strong Motion Fee: IBSEISMICO NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc ). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/11) Mech. Plan Check 0.0 1 hrs $0.00 Phunb. Plan Check Elec. Plan Check Mech. Permit Fee: IMPERMIT Plumb. Permit Fee: Elec. Permit Fee: Other Mech. Insp. Elhrs $45.00 Orlrer Plumb Insp. C Other Elec. Insp. C ldech. Insp. Fee. Plumb. hsp. Fee: Elec. Insp, Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc ). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/11) FEE QTY/FEE MRSC ITEMS Plan Check Fee: SzrPpl. PC Fee PME Plan Check: $0.00 Permit .Fee: Suppl. Insp Fee PME Unit Fee: $3,724.00 PME Permit Fee: $45.00 Consiruction .Tax: Administrative Fee: (ADMIN $42.00 Work Without Permit? 0 Yes E) No $0.00 Aclvancec/ Planning Fees: a Travel Documentation Fee: ITRA VDOC $45.00 Strong Motion Fee: IBSEISMICO $63.00 Select an Administrative Item Bldg Stds Commission Fee. IBCBSC $12.00 SUBTOTALS: $3,931.00 $0.00 TOTAL FEE: $3,931.00 Revised: 07/01/2012