12110103 CRT Y OF CU PIERTffNO Buff LDffNG PERMIT
BURLDING ADDRESS: 10500 N DE ANZA BLVD CONTRACTOR:ICOM MECHANICAL INC PERMIT NO: 12110103
OWNER'S NAME: MISSION WEST PROPERTIES LP IV 477 BURKE ST DATE ISSUED:02/26/2013
OWNER'S PHONE: 4089961010 SAN JOSE,CA 95112 PHONE NO:(408)792-2292
® LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
License Class CzJC-5& 6 Lic.# Ok4 Z 2- APPLE-CRITICAL REPAIRS TO.EXISTING CHILLED
�.�, � WATERICt
Contractor ICOM 6Qgjb dd Date SYSTEM AND REPLACEMENT OF COOLING TOWER
I hereby affirm that I am licensed under the provisions of Chapter 9 PADSDUE
(commencing with Section 7000)of Division 3 of the Business&Professions TO STRUCTURAL FAILURES,CORROSION AND TERMITE
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
1 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:$1000000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:31622017.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT]EXPOS IF WORK IS NOT STAIIt'1<']EIID
correct.I agree to comply with all city and couny ordinances and state laws relating WITHIN fl�0 DAYS OF PERMIT�SS�IAIVC]E®I[$
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 DA ]E2OM]LAST CALLED INSPECTION-.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and.expenses which may accrue against said City in consequence of the p�i�(B 2
granting`of this permit Additio t cant understands and will comply Issued by: IlDate: J
with all non-point ce re ations r the upertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date ��1 l 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:
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. 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 do 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,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 thePs255',0
Area uality Management District I
performance,of the work for which this permit is issued. will maintain compliance with thepr' o ISI i ' 1 Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health do Safety Code,Secti 3 , n 25534..
Section 3700 of the Labor.Code,for the performance of the work for which this
Owner or authorized agent: 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,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
FEE IESTMATOR—BUIDLMNG DMRON
ADDRESS: 90500 n de anza blvd DATE: 11/16/2012 REVIEWED BY: larrys
APN: 1BP#: /0? *VALUATION: 1$1,000,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY Commercial Building PENTAMAT➢ON 1GENCOM
USE: I PERMIT TYPE: d
WORK critical repairs to existingchilled waters stem and replacement of coolingtower ads due to structural
SCOPE failures, corrosion and termite damage toexisting enclosure.
Mech.Plan Check 0.0 hrs $0.00
Mech.Permit Fee: IMPERMIT
Other Mech.Insp. 0.0 hrs $45.00 ;)I,c t':=:-.: -l;zt/. Ell UiN,l !Jc f. J?r,p. Li I
t/,'.'l 'a 1"". 11!" h /rsp. I a h7r r. Ina p" i"("-
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These Lees are based on the prefindua information available and are onl an estimate. Contact the De t or addn I info,
FEE ITEMS(Fee Resolution 11-053 Efi. 7,11/12) FEE QTY/FEE MIISC ITEMS
Plan Check Fee: $0.00 = 1.f. Fence
Suppl. PC Fee: 0 Reg. ® OT Q,Q hrs $0.00 $1,198.00 IFENCEMAS> Fence,Masonry>6'
PME Plan Check: $0.00 = # Mechanical
Permit Fee: $0.00 $399.00 IMCRAA Evap Cooling System
Suppl. Insp. Fee-0 Reg. 0 OT 0 0 hrs $0.00 = 1.£ Retaining Wall
PME Unit Fee: $0.00 $3,594.00 IRETSP10 Special Design, (>10')
PME Permit Fee: $45.00
Administrative Fee: IADMIN $42.00
Work Without Permit? 0 Yes 0 No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRA VDOC $45.00 Building or Structure 0
d
Strong Motion Fee: IBSEISMICO $210.00 Select an Administrative Item
BldiZ Stds Commission Fee: IBCBSC $40.00
SUBTOTALS: 1 $382.00 $5,191.00 TOTAL FEE: 1 $5,573.00
Revised: 10/01/2012