12060109CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20400 MARIANI AVE
OWNER'S NAME: MISSION WEST PROPERTIES
OWNER'S PHONE: 4087250700
❑ LICENSED CONTRACTOR'S DECLARATION
License Class C` Lic l 1-�
Contractor ( I Date
1 hereby affirm that 1 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
performance of the work for which this permit is issued.
I 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.
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
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses whi may ac against said City in consequence of the
granting of this perm' . ddi ' ally, he applicant understands and will comply
with all non -point cc ulati r the Cupertino Municipal Code, Section
9.18.
Signature Date �"'I_
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
I 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.
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
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
upon the above mentioned property for inspection purposes. (We) agree to save
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
with all non -point source regulations per the Cupertino Municipal Code, Section
9. 18.
CONTRACTOR: ICOM MECHANICAL INC PERMIT NO: 12060109
477 BURKE ST DATE ISSUED: 06/29/2012
SAN JOSE, CA 95112 PHONE NO: (408)792-2292
BUILDING PERMIT INFO: BLDG I— ELECT r— PLUMB
MECH r RESIDENTIAL T_ COMMERCIAL I —
JOB DESCRIPTION: REPLACE EXISTING CDA EQUIPMENT (COMPRESSED AIR
SYSTEM)AND INSTALL NEW EXHAUST FAN
Sq. Ft Floor Area: I Valuation: $104000
APN Number: 31622018.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 D YS FRO AST CALLED INSPECTION.
L r • / t--
Issued bv. Date:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants de the Bay Area Air Quality Management District I will
maintain nee a Cupertino Municipal Code, Chapter 9.12 and the
Health etty Co , ec ons 25505, 25533, and 25534.
FW;; W I
TI M
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of mrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Ad
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date I Licensed Professional
Fm-i
CITYOF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
-
ADDRESS: 20400 Marian! Ave
DATE: 06/18/2012
REVIEWED BY: A. Salvador
APN:
BP#: 12060109
`VALUATION: 1$104,000
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
USE:
PENTAMATION 1CMAP1
PERMIT TYPE:
WORK
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY
UNITS
BP FEES
Other Appliance/Equip
16APPLOT
1
#
$65
TOTALS:
$65.00
Mech. Plan Check 4.0 hrs $520.00
iMECPLNC I Mech. Permit Fee: iMPERMIT
Other Mech. Insp. 1 4.0 1 hrs $44.00
; „::, :: ! ,
Mech. Insp. Fee: IMECHINSP $520.00
,,..•;.
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District etc.). Thesefees are based on the prelinddna information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E,f. 7/1/11)
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$520.00
PME Unit Fee:
$65.00
PME Permit Fee:
$564.00
- 'e r-s r4 Y1 r,'Y 7(3i',
Administrative Fee: IADMIN
$41.00
Work Without Permit? 0 Yes (j) No
$0.00
A
Travel Documentation Fee: ITRAVDOC
$44.00
Strong Motion Fee: IBSEISMICO
$21.84
Select an Administrative Item
Bldy Stds Commission Fee: IBCBSC
$5.00
SUBTOTALS:
1 $1,260.841
$0.00 TOTAL FEE:
1 $1,260.84
Revised: 06/30/2012
CITY OF CUPERTINO
FM__7 FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20400 Mariani Ave
DATE: 06/18/2012
REVIEWED BYASean
APN:
BP#: �a�d�j D�D
`VALUAT : $104,000
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / dition / Repair
PRIMARY Commercial Building
USE:
PE AMATION
PERMIT TYPE:
WORK
Replace CDA equipment (compressed airs stem and install new a aust fan.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY
UNITS
BP FEES
Select a Mech Item
TOTALS:
$0.00
Mech. Plan Check 4.0 hrs $520.00
ern
.• C;_
IMECPLNC Mech. Permit Fee: IMPERMIT
Other Mech. Insp. 1 4.0 1 hrs $44.00
Odwr- lorrrfi ln.sp�
0:: �cLi
Mech. Insp. Fee: IMECHINSP $520.00
Plr ,h l spr. Fee
h.7er . 1r, r ; .. .
NOTE: This estimate does not include fees due o other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. eta). These fees are based on the or iminary information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS Fee Resolution 11-053 E 711111
FEE
QTY/FEE
MISC ITEMS
Plan C'lnc•k Fee:
Suhhl. PC Fee e
PME Plan Check:
$520.00
.. l. ILrsh FCC
PME Unit Fee:
$0.00
PME Permit Fee:
$564.00
Administrative F e: IADMIN
$41.00
Work Without ermit? 0 Yes (j) No
$0.00
'Idl-unE•ec/ Plarmin" Fee).
Travel Documentation Fee: ITPA VDOC
$44.00
Strong Motion Fee: IBSEISMICO
$21.84
Select an Administrative Item
Bldy Stds Commission Fee: IBCBSC
$5.00
SUBTOTAL S:
$1,195.84
$0.00 TOTAL FEE:
1 $1,195.84
Revised: 06/30/2012