13060042 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20650 VALLEY GREEN DR CONTRACTOR:ICOM MECHANICAL INC PERMIT NO:13060042
OWNER'S NAME: SI 50 LLC 477 BURKE ST DATE ISSUED:06/06/2013
OWNER'S PHONE: 4089961010 SAN JOSE,CA 95112 PHONE NO:(408)792-2292
13 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALD COMMERCIAL®
--12
License Clas,4;0'C5('1:!5 Li,.4 4/t)h+ -Z- APPLE-INSTALL NEW INLINE FURNACE IN
MECHANICAL
Contractor t4o �IbW tp,h, PAD,DUCT PENETRATION INTO BUILDING,TIE INTO
I hereby affirm that I am licensed under the provisions of Chapter 9 EXISTING HEATING DUCT
(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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$60000
1 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:32610053.00 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 D YS OF PERMIT ISSUANCE OR
an
to building construction, d hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY LAST CALLED INSPICTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, '
costs,and e d City in consequence of the
g,rue-against said i
expenses
wh may a,,
granting,f thise, it —onallyt applicant understands and will comply Issued by: Da
with all non-poi qrsqdrccA gulatio er the Cupertino Municipal Code,Section F Y
9.18,
RE-ROOFS:
Signature DateP—)6�( D 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.
0 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. 1 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 nip r evices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by th ea lity Management District I
performance of the work for which this permit is issued. will maintain compliance with t u ertin unci al Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sect* s 25 5,-1 5533,an 25534.
qq
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date
permit is issued. GE
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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I
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
APPLICANTCERTIFICATION 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
indemnity 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: 20650 valley green DATE: 036/0612013 REVIEWED BY: Mendez
APN: BP#: } *VALUATION; $60,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1GENC0 i
wORK a le- install new inline furnace in mechanical pad, duct penetration into buildingtie into existing
SCOPE heating duct
77-777,
:,Wc/t, Ptarry(.".heck ('lrt Tb, Irapa Cheek E/n,.'. Plan(.,'heck
Lfsc,r?. PenWl.Fec?: I'drimb,Permit Fee: lsl€c.. Permif Fec::
£7rlaer°Mec h,insp., t iher f'lUMb MIT. Other Glee.Inst.
P2�Lj
Plumb, Irf.;lr,Fee: Glet. Ins Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary,Sewer District,Schaal
District,eta . These ees are based on the relimina in ormation available and are onl an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 11-053 LE 711112 FEE QTY/FEE MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes (E) No $0.00 1 hours Plan Check,Hourly
Suppl. PC Fee: iq Reg. 0 OT 0.0 hrs $0.00 $133.00 ISTPLNCK
PME Plan Check: $0.00
Permit Fee: Hourly Only? 0 Yes No $0.00
Suppl. Insp.Feer Reg. 0 OT 4.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
("Onstruc tion :Tax.
dminis irative.Fee. 0
Work Without Permit? 0 Yes 0 No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential
1 1Documentation Fees: Building or Structure 0
Strong Motion.Fee: 1BSEISMICt1 $12.60 3.0 hrs Inspections
Bldg Stds Commission Fee: IBCBSC $3.00 $399.00 IsnNSP Inspection,Hourly
llx�cTaLr
$156=0 $532. .00 T()I'AL FES: $547.60
Revised: 04129/2013