13110017 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20525 MARIANI AVE CONTRACTOR:XL CONSTRUCTION PERMIT NO: 13110017
OWNER'S NAME: 20525 MARIANI DRIVE LP 851 BUCKEYE CT DATE ISSUED: 11/22/2013
OWNER'S PHONE: 4086216261 MILPITAS,CA 95035 PHONE NO:(408)240-6000
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class_ Lic.# u80 APPLE-INSTALL AND ANCHOR A MECHANICAL
I, MOBILE
Contractor )(L 'Cor+s�ru�Ton Date Nl2413 SHELVING SYSTEM WITHIN AN EXISTING LAB 350 SQ FT
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&i 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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation.$5000
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: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 WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT 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 FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, l
costs,and e�i crises which may accrue against said City in consequence of the �granting?f th permit. Additionally,the applicant understands and will comply Issued by: A/R�G�� Date:
II��
with all non-po t source egula[ions per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature / Date 1 1 13 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.
CI OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License.Law for one of Signature of Applicant: Date:
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 haveread the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penaltyof 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 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self insure for Worker's material. Additionally,shout use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,'for the air contaminants as defined a Bay Area Air Quality Management District I
performance of the work for which this permit is issued.: will maintain compliance wit th Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sdo s 25505 5533, nd 25534.
Section 3700 of the Labor.Code,for the performance of the work for which this Owner or authorized agent: �' Date: I l t 1
permit is issued.
I certify that in the performance of the work for which this permit is issued,l shall
not employ any person in any manner so as to become subject tothe 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.1 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
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 20525 mariani ave DATE: 1110412013 REVIEWED BY: Mendez
APN: BP#: *VALUATION: $5,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION 1GENCOM
USE: PERMIT TYPE:
WORK a le- install and anchor a mechanical mobile shelving system within an existi nq lab 500sq ft
SCOPE
tLfec:h. Plan Check P1 11111b. Plan Check Elec.Plan Check
iLfech. 1'erruit Fee: Phtmb. Permit Fee: Fie(% Permit Fee:
Other iklech.Insp. Other Phwnb Insp. Li Other F,lec.Insp.
I.Alech, Ins).Fee: Plumh. Insp. Pee. Elec, Insp,Fee:
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS(Fee Resolution 11-053 Ef. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? ()Yes E) No $0.00 2 hours Plan Check,Hourly
Suppl.PC Fee: Q Reg. .Q OT 10701 hrs $0.00 $278.00 1STPLNCK
PME Plan Check: $0.00
Pen-nit Fee: Hourly Only? ().Yes (D No $0.00
Suppl. Insp. Fee-0 Reg. Q OT0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Conswuction Tax:
Adrninistrative Fee:
Work Without Permit? O Yes O No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Docinnentution Fees: Building or Structure O
Strong Motion Fee: 1BSEISAfICO $1.05 4.0 hrs Inspections
Bldg Stds Commission Fee: IBCBSC $1.00 $556.00 ISTINSP Inspection,Hourly
SUBTOTALS: $2.05 $834.00 TOTAL FEE: $836.05
Revised: 10/01/2013