11070013 (2) CITY OF C-UPERTINO'B;UILDING;PERMITREVISlON' `
'BUILDING;ADDRESS: 10200 N'TANTAIJ AVE CONTRACTOR:THERMAL, DN :° 70013'
'MECHANICAL.
OWNER'S'NAME:roROCKTWO FEE;'LLC 425 ALDO AVE DATE,ISSUED;07/01/201,1
OWNER'S PHONE: 4084525900' SANTA,CLARA,CA 95054. PHONE NO:,(408)9994744
0 LICENSED+CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL Ll COMMERCIALE]
GG
'License Class,; 7i5&1� 1'0100'& 10200 N TANTAU-OUTSIDE,MECHANICAL YARD=. .
C-Z �. /tic #' COOLING TOW_ER,REPLACEMENT
Contractor;
11iheeeby affirm
firm�IGthiatti+ ,arn licensed under'.a,hileop}�roatve
sionsoChapt�
9/62014=REVISIQN#1_ CHILLER REPLACEMENT-ISSD
:('commencing with Section'7000);'of Divi"sion�Xiif;the Business,&;Professions 10/19/2011
Code and tl at`my licensplis in full force and effect.
[;hereby afTrm,under penaltyot"pgjury,one'of.tlie following:itwo declarations:
I.have:and wih maintam;a;ceitific'ate of consent to;self-.ins'ure for Worker s
Compensation,asyrovidedfor by_Section 3700,of the Labor Code,forthe
peiformance of the work forAwhich"this`permifi's°'issued. Sq.Ft Floor Area: Valuation_$200000.
I'haye,and will maintain.Worker's,Compensati6ri,,I isurance;as;,pr'ovided for by "
SecU6n3700 of,theLaborCode,for the.pefformance ofthe.work forwhich°this
APN Number:3'161906i.00 Occupancy Type:
permit,is issued:
APPLICANT CERTIFICATION
d certify'that 1,haveiread thislapplication and state,thatthe above information is PERMIT EXPIRES•IF WORK:IS NOT STARTED
correct:1 agree to'.comply with 411 city,and county ordi'a"nces,and�staterlaws velating
to budding;constfu,W.dn and;hereby authorize,representatives of this,�city,to enter WITHIN 180",DAYS,OF PERMIT ISSUANCE OR:
upon,iAe, ove,mentibhed'propeity'for inspecb6n,purposes. (�We)agree io,save 18.0. 1 DAYS FROM:LAST CALLED INSPECTION.
indernnifyland''keep'..harriless-the.City,' fCupertino.against`habilities,judgments,
=costsand expenses which,may accme;agamst said City inconsequence of the Issued b Date:
granpnggof ,this'permrt: Additionally,the apple'cant unders lids"id,Ill comply Y.�.
with all non ppoint,sourcekregulations'par the Capertino Municipal,Code,Section.
�Si nature Dates G'• All roofs,shall.be ins_ccted prior to;an .ro RE-ROOFS:,
RE-R
g -y ling material being installed.Ifa�roofi§i-
installed:without,first obtaining an inspection,I:agree to remove,all.new inaterials for.
inspection.
0 OWNER-BUILDER UiSLARATION
'Signature;of,Applicant:. 'Date;,
I tiereby_-aff rm that. am;exempt1rom the Confractor'sLicense Law for one of
'the Winwingitwo reasons: ALL ROOF COVERINGS TO BE CLASS"'A"'OR BETTER
I,asbwnerofthe:property,or,my,employees°with wdfi
ages.aseirf`§6ie compensation;
Will do,113e-work,;and M6e structure is"not intended;oi offered•for+sale(Sec:,7044,
Business*Professions.Code).
I,.as,owner ofthe property,am•exclusively contracting w.ith,[icensed contractors;to HAZARDOUS„MATERIALS=DISCLOSURE.
,constmct theprojed_(Sec:704;4,=Business,,&Professions Code).,, 'read ttie','tiazardous materials requirements under Chapter 6:95�of the
California Health_&iSafety Code;Sections 25505,,25533,and'25534. Twill
Ihereb
a
y; Wrm,under penalty ofperjury one,of the=foll`owiog jbirm maintain compliance with,the Cupertino Municipal Code,Chapter 9'11and the
declarations: Health&-,SafetyaCode.Section 25532(a)should I store,or tiaddle,hazardous
I have and:will ftiaintainra Certificate of Consent to!self-insure for Worker's material. Additi'onally;,shouid.l use equipment or dcvices•which emifhazar.4ous
Compensation,a s,,prbvidd&for.by'Sectiori 3700'ofthe Cabor.Codc;�forthe air confaminagfs as delrn"ed by the Bay Area Air Quality.,Managemeot District;l
performance of'the work for,whichihis;,permit.i`s'issued. will;maintaig compliance with'the'Capertino Municipal Code,Chapter,9.13 and
.1 have and,�wilt rnainta0n,Worker s;Compensffiion,Insuran%as pro_vided•for'by the,Health,&Sofety"Code,�Section's,25505;.25533,and 25534:•
Section 3700 of iheiLaboCtode;-foi l_h_c°performance;of themcirk.for whicli'this
peiriiit is+is`s'ued. Owner or authorized ae:gent-1 Dat .
Icertify'that;in the pe-rformanceiofthd Nvork;for�whichthis,permit°ssussued,`I-shall
noten5ploy any'person many.,manner so as,to become,sub ject�to-the Worker;s
Compensation laws of California: If after making this°:certificate of:exempfion,l CONSTRUCTION'LENDING AGENCY
become subjectto;tlie:Worker-:si,Compensation.provisions.ofthcaLabor Code,I must (hereby affirm'thafthere'is a;construction lending agency for the,performance:of'
foriliwith'co_mplywith such;provksron'_s�or'thi's.perinf shall be"deemed;revoked: wor'k's;far which,this permit=is issued(Sec_3097;Civ,C:)
Lender's,Name.
APPLICANT CERTIFICATION L_eoder_'s Address
Ircert fy that 1,havc cad4his;appljcation and,stafe°that the^above-information is
` correct 1`agreeto complyswith all city;and county ordinances.and state°laws relating
to building�coristructron,,and=hereby authonze re preseIntatives,ofthis,city to;enter
upon the_above mentioned property forJnspection;purposes (We);agree to_save - -
. ,
ARCHITECT-
'S DECLARATION
indmnifYsandkee :harmless'theCity ofCupertino a amst liabilitiesJud mems,e
'costs,and expenses whidi.may'accrue agamst•sad I understand-my,plans shall be used as'public recordsl_o
grantin'g;ofihis permit Additionally;the applicanGundentands;and'Wit I comply
with all non point>sourceiregulations•pe-the Cupertino Municipal Code,Section Licensed Professional
9'.181.
Signature Date
CIT.Y`OF:CUPERTINO BUILDING PERMIT
RUILDING ADDRESS 10200 N TANTAU AVE 'CONTRACTOR:THERMAL MECHANICAL PERIVIITNO ;]1070013' .
QWNEWS NASIE:'"[OCKTINO F6E,LLC. 8,435 ALDO.AVE DATE ISSUED G07/Of'lfOI,1
,
.OWNER'S PHONE:,408452.5900 SANTA CLARA,CA-;95054 PHONE NO.'(408)988'8744-
-LICENSED CONTRACTOR'S:DECLAR:&TION f7
_ P B LEC PL
C, C —7
'BUILDING-PE INFO: LDG' E T UMB` "
License ClassG3 Lic# 'J J s' - '
NIECH RESIDENTIAL1_E, COMMERCIAL
Contractor �•�i�✓s�al �G�i!Iy?.lk�Date
I liereb ffir w that
F trop cense of Division 3 ro the Bs, f hapter9 B DESCRIPTIONREPLACEM :.OUTSIDE;MECHANICAL YARD-COO_tiING TOWER
y ffirm that I am licensed ander the proyrsions o
(commenc' ness&_ ,Professions:
Code and?thatmy license is tnfull"force,and,effect:
hereby�Mfiirm'dnder'peiialty of perji ry one of the,foho-wing,two declarations>
"I have and`will.maimain a-certificatc`of consent to self insure for,Worker's:
Compensation,as pr6vided'for by Section 3700 of-the:L•abo 'Code - for the"
performance ofthe-w,ork for which this permit is issued,
l'have and will'.maintain'Wotker,s Compensation Insurance„as 6t6vided.f6r46y `Sq.,Ft Floor Area:• Vail uation:,$200000
Section 3700:(of the LaborCode;for the performance,of the work,for which this
perrnitiis.is§u&d.
APN Num6er:`3161.9061.00 Occupancy-Type:
APPLICANT CERTIFICATION
l certify-thatI-hade�read'this application^dn state that;tlie?atiove inforinatioh,is
66ftecf.liagree"to coin-I'With al city'And;county ordinances and state,laws�relating
uponilding ttieabovesment oned propertyfor inspectionrize rpurposese( e)tis city to enter - P
agree to save PERMIT EXPIRES.IF WORK IS NOT:STARTED'
mdemmfy and keep;harmlessthe-City.of Cupertinoiagainst lia6drties;judgments, WITHIN 180 DAYS'.OF PERMIT ISSUANCE',.OR
costs and expenses which may acenie agairist said•City in=consequence-at e 180 DAYS,FROM LAST CALLED INSPECTION.
granting of this perriiit. Additionally,the,applicantunderstandsand'w 11 comply
wiih all non-poinCsource regulations per the_Cupertino Municipal"C-od'e;Section
9:18. Issued by: - .Date::
• Signatiir'e / � Date
❑_ OWNER-BUILDERMECLARATION RE-ROOFS:
P msltroofs alled mall be inspected,prior to any rooting material bengtimstalled•If a roof is
'I herebyaffrm that;I am,exem -tfrom,the Contractor's Lieeose,Law:for one of ithoiII tirst•obtaming=an inspection„I agree to,reniove;all newematerialsfor
the4 o,114wing two reasons: inspection.
I,as owner of the0ci erty of my employeeswith wages--As their solecompensation',
will do;4he wQrk,7gnd",the�structure isnot-iriten_d_ed.or:offered for sale;(Sec7044;, Signature-ofApplicant- - Dater
31fsmesst&Professions Code) -
I,-8 owner of the property,am.exclusively contracting with Licensed contractors,to
cohsttuct,tfie,project(5ed17O44,,,Bi sihe§s&Professions Code)_ ALL ROOF.COVERINGS TO BE CLASS"A"OR,BETTER
fh'ereby,affirm under penalty*of perjury one'of the"following=,three.
_ d_eclarations: HAZARDOUS,NIATERIALS`DISCLOSURE'
I have and=will-mauitain,a Certificate ofConsent.to self-insure fot Worker's 1 have read the;liazardo_usmaterials requirements under Chapter 6:95 of the
Compensation as,`ptoy ided",forby;Section 3.700.of the Labor Code;for the California Health&Safety,Code,Sections 25505,,25533,and 25534. I wilLmaintain
perfotmance of:the`"work''�forwhich,tfiis�+perinifis,issued. � coinpliance,witti the;Cupei ino Nldnicipal.Coile;Chap ter,9421and,the AeAth&
I have=and will,,mainiain-Worker's,,Compensati-on;Insurance,,as provided for by Safety?Code,,Seeiion,25532(a),should Ustor_,e or handle hazardous material;
= Additionally,should 1 use equrpme[t or devices=which emit hazardous.air
Secuon'3700 oftheeLabor Code;fortheperformance;ofthe,work;focwhich this
mamtain:com liance..with the Cupertino Air.Quality',Management District1 will.
contaminants as defined b Tthe Ba' Area
permit iswissued: - P p Municipal,Code,'Chapter 9.13 and the
I°c•ertify'that'inthe performance�of the.work for whichA hispermiris jssued;'.I shall Health&~Safety,Code,Sections.2550525533,and 2553.4.
notaemploy any,person inaany�manner so.as,to�become:subject.tosthe`Wotker's'
Compensation laws of California if after making"ihis;certificate ofexemption,I Owner h ed t:
become subject to the Worker's_Conipensation�pfovisions=of.tne Labor Code,I must � ' Date:
forthwiihicomply wrtb,such,provisions"or thispermif shall be deemed revoked.
CONSTRUCTION'EENDING AGENCY..
APPLICANT':CERTIFICATION. -I hereby affirm,that there is aconstmction,ending agency for-the performance ofmrk's
certify,tbat-,I have read.this%application and statc,tliat the above idformatibn-is, for which this"perm_ itis issued'(Seo.3097 Civ,-C:)
correct.I agrec6to,c6mply with'all cityand county:;ordinances:and,;sta`te laws-relating Lender's Name
uo;oml"ding,0nstruotion,and hereby authorize representatives of this city to enter
-
upon_n the,above mentioned+property formspection5purposes:.(We)agree to save Lender's Address
indemnify and keepandrmlessahe CityofCupertino againstliabilities;judgments,
costs and expenses which may`dif&&against said City in consequence of the
granting oPthis+permit..Additionally,'the applicant understands and'wi11 comply° ARCHITECT''-S DECLARATION
mifh�all non`point;source regulationsper the Cupertino,Municipal Code Section I understand mv`plans�shall beused as�public-records.
"9A_&
Licensed Professional
Signature, Date
CITY OF.CTPERTINO
FEE ESTIMATOR-RUILDING D.IVISION
ADDRESS: 1'0200 n tantau ave DATE: 09/664011 AEVIEVVED,BYc la"..s
APN: BP#.c / "VALUATION: 1$214,060,
;r -
PERNIIT`TYP,-E: Mechanical,Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRJMA_RY CoPENTAMATION
mmercial Building FURN%AC
USE: PERMIT TYPE:
WORK chiller re laceroent
SCOPE
APPLIANCE'/EQUIP TYPE, FEE ID Q.TY UNITS BP;FEES
Evap Cooling.System 1'MCRAA. 1 # $130
'TOTALS':
$130.00
111111 '. Oil Iyi�;.. = 13,3 1P 4g,
3 311 > t i 3 11, I g
3 17
3,
�,M ..F '9� ,331.E :? �3u'f'�-
Mech.Plan Check6.0 hrs. $780:00
LMECPLNG Mech.Permit Fee:,,1 MPRRMjY
Other Mech.'Iw. 0:0' hrs. $44.00 �..: „ ?f:Y;. LJ
%4.
: rr. is
NOTE: These: ees,are�6ased on°the, reliniinar,information ava'ilabl6anddre lonl`an stim-d--te: Contact the'De p t ofaddnrl=in o.
FEE',ITEMS.(hee 1Zks��1u/iis�z.l'l-0.53 F 7�tial ' FEE Q.TYLFEE 1VLISC`ITEMS.
PME Plan Check: $780..00
PME.Uni't_Fee:- $130.00
PME-Permit,fee:, $44.00
Work Without Permit? Q Yes E) No $0.:00''
Travel..°Documentati'on,F.m 7-._.-. -__OC $44.00 d
Strong My otion'Fec: IBSEISMICO $44.94 F2.07 hrs Inspections
131id�,y St6,Commission,Fee: IBC-BSC $9:00 '$260.00 IMNSP Inspection,:H'ourly
a_
SVBT�OTALS $1,051.94 $260.00 .. TOTAL FEE $1,311.:94
Revised: 07/,04/201.1
CITY'OF,CUPERTINO
FEE ESTIMATOR--:BUILDING.DIVISION
ADDRESS: 10200 4antau ave. DATE. 07/01/201`1 RtV-EWED BY: bobs:
APN: BP#: Q VALUATION: $200,000
'-,PERMIT TYPE: Meeh-apical Permit PLAN'CHECK TYPE: Al-terati'on /Addition./ Repair
PRIMARY SFD'or Duplex PENTAMATION FURNYAC_
USE: PERMIT TYPE:
,WORK '
SCOPE
APPLIANCE./EQUIP TYPE ;FEE ID, QTY' UNITS BP FEES-
,Cooling System 1M_RRAA, 1 # $�3'
TOTALS:: $63.00.
III 3h �}}O
ff
13 353 = 7u�YIF
Wch.'Alan-.Cl eck lits moo
Mech.,Permlf.Fee: IMPERMIT. -
Qther'Mech.Insp. 0.0 h"rs $42 El
O,,,.,
NOTE:•These,i ees are,,dased on.thef reliMina�:,in ormathmn available and;are on&wn;estimate _
.,Contact the Ve `t orraddn'i,in o.
FEE EM F1'ee Izescluti�r>�9 05d, ;ff I%I( FEE QTY%EEE° MISC ITEMS
PME•Plan Check: $0.00,
ma8`O itFee.: $03.,00.
P.W.P& t'Fee. $42:00
Work Without Permit? 0 Yes G No $0.00
Travel.Documentation:F.ee: ITRA,vDOC $ 00
'Sfron�4:M.ofictn Fee: IBSEISMCR. - $2 1•.0 hrs Inspections
,1314 St&Conrniission-Fee, I.BCBSC $8,00. $:130.00 ISTINSP Standard:Inspections,
3
SUBTOTALS 175.00 130.00; TOTAOFEE� ' '
$ $305.00
Revised:.07/01/201.1
• J
' / r