12080320I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20605 VALLEY GREEN DR
OWNER'S NAME: BERG FAMILY PARTNERS, L.P
OWNER'S PHONE: 4087250700
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #_ 9
� 63
SUsj2
Contractor (taco 1Q( ! Date
1 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.
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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 1 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 applican
2 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
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETI'ER
HAZARDOUS MATERIALS DISCLOSURE
1 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 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality � ana ment District I
will maintain compliance with the Cupertino Municipal de apter 9.12 and
the health & Safety Code, Secti ns 25505, 25533, an 34.
Owner or authorized agent: te:
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
ARCIIITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Profess
Signature
Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS:
DATE.
REVIEWED BY:
APN:
BP#:
`VALUATION: $26,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
USE: Commercial Building
PENTAMATION
PERMIT TYPE: FURN/A A
WORK
remove and replace one 350 MBH rooftop furnace heater
SCOPE
Mech. Plan Check 0.0 hrs $0.00
Plurnh. Plan Check
Elec. Play, Check
Mech. Permit Fee: I MPERMIT
Phnrrh. AT11 it hea .
EG:c. Prrnrit Fee:
Other Mech. Insp.onccr
Ej�hrs$45_00
1nrh 'luhnp.ET-1-
Other Elea. Imp. Ll
Aiech. Insp. Fee:
Plronh. hasp. Fee:
Elee. by p. h'ee
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution I1-053 Eff. 7/I/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0,00
1- #
\
Mechanical
%/� Furnace, Floor
Suppl. PC Fee: � Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. 0 OTT
0 .01
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$45.00
C onstruclion T4ix:
Administrative Fee: MDMIN
$42.00
0
(D
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential 0
Building or Structure 0
A
Travel Documentation Fee: ITRAVDOC
$45.00
Strong Motion Fee: 1 BSEISMICO
$5.46
Select an Administrative Item ll
,` Lp
Bldg Stds Commission Fee: IBCBSC
$2.00
SUBTOTALS:
$139.46
$67-TO
TOTAL FEE: $2�6 46
Revised: 07/01/2012