12060115CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20400 MARIAM AVE I CONTRACTOR: ICOM MECHANICAL INC I PERMIT NO: 12060115
OWNER'S NAME: MISSION WEST PROPERTIES 1 477 BURKE ST I DATE ISSUED: 06/19/2012 1
OWNER'S PHONE: 4087250700 1 SAN JOSE, CA 95112 1 PHONE NO: (408)792-2292 1
❑ LICENSED CONTRACTOR'S DECLARATION
License Class b �Z_L,ic. #
Contractor 1 com 1 (17, ILI
I 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 w 'ch may accrue against said City in consequence of the
granting of this pe rt Additio -y a applicant understands and will comply
with all non -poi s rcere ation the Cupertino Municipal Code, Section
9.18.
Date 92F
' `_ _1Mr__
❑ 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.
JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
DEMO EQUIPMENT IN MECHANICAL ROOM, REMOVE
CDA
EQUIPMENT AND EXHAUST DUCT PRIOR TO
INSTALLATION
OF NEW CDA SYSTEM AND EXHAUST DUCT 250 SQ FT
Sq. Ft Floor Area: I Valuation: $5000
APN Number: 31622018.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAY OM LAST CALLED INSPECTION.
Issued by: C Dateo-/,f ,
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
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. 1 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 as defined by th ay Ar ality Management District I
will maintain compliance with t u tino ni ipal Code, Chapter 9.12 and
the Health & Safety Code, Sec ' ns 2 505 3, nd 25534.
Owner or authorized agent Date.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Date
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 20400 MARIAM AVE
DATE: 06/19/2012
REVIEWED BY: Sylvia
APN:
BP#:
"VALUATION:
1$5,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Buildin
USE: g
PENTAMATION /',I
PERMIT TYPE: VL/ eviCU
WORK
Demo equipment in Mechanical room remove CDA equipment and exhaust duct prior to installation of
SCOPE
new CDA system and exhaust duct 250 sq ft
1h-4 h, Man C'he,(.
P/Wflh, Pl(n CI)CCA
EJec. Plan C'hrcl
t111 PtPrrnr I t'r"
F'lrrmh. 1'61-;
As ec. Pcmir Fcc
Ori r Phanh lrutr.
Oilier Oec Insp,
'ti t �� /n:•p. 1%i<e:
I'hm�b. hop,
Elec. Insp. h cc ,
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. eta). These fees are based on the Dreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 E f . 711111)
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. O OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? O Yes G No
Suppl. Insp. Fee:Q Reg. O OT 0.0 hrs
$0.00
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Consowcnon Tax:
,l drnirris trative Fc c:
O
0
Work Without Permit? O Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
1 hours Inspections O
$130.00 ISTINSP Inspection, Hourly 0
Travel Docrrm raaiivn
Strong Motion Fee: IBSEISMICO
$1.05
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$2.051
$130.00 TOTAL FEE:
1 $132.05
Revised: 06/30/2012