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12110049 (2)CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10900 N BLANEY AVE CONTRACTOR: MATRIX HG, INC. PERMIT NO: 12110049 OWNER'S NAME: PACIFIC GAS AND ELECTRIC CO 2355 WHITMAN RD STE A DATE ISSUED: 11/08/2012 OWNER'S PHONE: 4153173740 CONCORD, CA 94518 PHONE NO: (925) 459-9200 ❑ LICENSED CONTRA R'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL G !O r License Class �Lic. 2 �L[ # � � 2 Z 3 BUILDING C- REPLACE 4 ROOFTOP PACKAGE UNITS Contractor TM A♦C' j X 6 1 W O Date If—T—(2, 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: $252847 performance of the work for which this permit is issued. 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 permit is issued. APN Number: 31603045.00 Occupancy Type: 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. 1 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 DAY F OM 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 �,(/� Z+ granting of this permit. Additionally, the applicant understands and will comply Issued by: / Date: u with all non -poi urce regulations per the Cupertino Municipal Code, Section 9.18. y Signature Date i 0 r L RE -ROOFS: 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) 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 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 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 1 performance of the work for which this permit is issued. will maintain compliance with the Cu lino Municipal Code, Chapter 9.12 and I have and .will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 2:r0 1, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: i 1 (Z 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 permi . dditionally, the applicant understands and will comply with all non -point so r regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature —.— Date f t �� -_ go, CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION Mech. Plan CheckT-001 hrs $0.00 ADDRESS: 10900 N BLANEY AVE DATE: 11/08/2012 REVIEWED BY: MENDEZ Other Mech. Insp. 0.0 hrs $45.00 APN: BP#: 'VALUATION: 1$252,847 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: 0.0 PENTAMATION FURN/AC PERMIT TYPE: WORK BUILDING C- REPLACE 4 ROOFTOP PACKAGE UNITS SCOPE 4 # $532.00 Mech. Plan CheckT-001 hrs $0.00 A1111111111111111 - -.-A Phlnnh. Plus ChccF Dec. Plan Cheek Mech. Permit Fee: IMPERMT PlrnnbPermit Fec. Elec, Permit Fee: Other Mech. Insp. 0.0 hrs $45.00 Other Plumh Insp.Li Other Elec, Insp. Li Alech. Insp. Fee: Plumh. Insp, Fee. Elec. Insp, Fec: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the nreliminary information availahle and are only an estimate. Contact the Dent for addh7 info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Q Reg. Q OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 4 # $532.00 Mechanical IBCAIRHA A/C Units (<=10K cfm) Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. FeeQ Reg. Q OT0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $45.00 Conswitclion Tnx: Administrative Fee: 1ADMIN $42.00 0 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee. $0.00 hours $266.00 Inspections ISTINSP Inspection, Hourly 0 ©� Travel Documentation Fee: ITRA VDOC $45.00 Strong Motion Fee: IBSEISMICO $53.10 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $11.00 SUBTOTALS: $196.10 $798.00 TOTAL FEE: $994.10 Revised: 10/01/2012