11030113CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10991 N DE ANZA BLVD
CONTRACTOR: SILICON VALLEY
PERMIT NO: 11030113
MECHANICAL
OWNER'S NAME: STAR ONE CREDIT UNION
2087 RINGWOOD AVE STE 50
DATE ISSUED: 03/28/2011
OWNER'S PHONE: 4085435077
SAN JOSE, CA 95131
PHONE NO: (408) 943-0380
❑ LICENSED CONTRACTOR'S DECLARATION
F r
PERMIT INFO: BLDG
BUILDING ELECT PLUMB
License Class Lic. #
MECH RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: STE A, STAR ONE CREDIT UNION - ADD GREENHECK
(commencing with Section 7000) of Division 3 of the Business & Professions
VENTILATION FAN IN EXISTING SERVER ROOM
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: $3000
l 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: 32610059.00
Occupancy Type:
APPLICANT CERTIFICATION
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
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18•
� �7 ll
Issued by, Dater J l
Q
Signature
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
All roofs shall be inspected prior to any roofing material berg installed. If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
the following two reasons:
inspection.
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,
Signature of Applicant: Date:
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
HAZARDOUS MATERIALS DISCLOSURE
1 have and will maintain a Certificate of Consent to self -insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(a) should I store or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued.
maintain compliance with the pertino Municipal Code, Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued, I shall
Health & Safety Code, Sec ' s 25505, 25533, and 25534.
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
Ow auth t: 3 -J-e-ff
become subject to the Worker's Compensation provisions of the Labor Code, I must
- Dat
777
forthwith comply with such provisions or this permit shall be deemed revoked.
77
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of %ork's
I certify that I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
ARCHITECT'S DECLARATION
with all non -point source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
FM-7 FEE ESTIMATOR — BUILDING DIVISION
lalADDRESS-
10991 n. dab
DATE: 0312812011
REVIEWED BY: larrys
APN:
I BP#:
*VALUATION: 1$3,000
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
USE:
PENTAMATION 1 CMAP8
PERMIT TYPE:
WORK
reenheck ceiling fan in server room
�add
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY
UNITS
BP FEES
Ventilation Fan
1BREMVENF
1
#
$21
TOTALS:
. . ......
$21.00::
NOTE.- These fees are haled nn the nrolindnary informatian availahle and are only an estimate. Cnntart the Dent for addnl info.
FEE ITEMS (Fee Resolution 09-051 Eff 711110)
FEE
QTY/FEE
MISC ITEMS
...................... -
PME Plan Check:
$0.00
..............
PME Unit Fee:
$21.00
PME Permit Fee:
$42.00
4 "A
Work Without Permit? 0 Yes G No
$0.00
Travel Documentation Fee: I TRA VDOC
$42.00
Stronp- Motion Fee: IBSEISARCO
$0.63
Travel Documentation
Bldg Stds Commission Fee: IBCBSC
"tW-0-:'
10
106.63
6 n63
$42.00
7-e
$ 1,W. 63]
M
Revised: 03/01/2011