11080092CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21710 STEVENS CREEK BLVD
CONTRACTOR: DE CARLI GORDON C AND
PERMIT NO: 11080092
JANET M TRUST
OWNER'S NAME:
21710 STEVENS CREEK BLVD STE 200
DATE ISSUED: 08/16/2011
OWNER'S PHONE:
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
r
"
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. #
MECH RESIDENTIAL ' COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REMOVE & REPLACE EXISTING HVAC UNIT
(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.
Sq. Ft Floor Area:
Valuation: $4500
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
APN Number: 35717038.00
Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
180 DAYS FROM LAST CALLED INSPECTION.
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
Issued by: Date:
9.18.
Signature Date
RE -ROOFS:
OWNER -BUILDER DECLARATION
7
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
1 hereby affirm that I am exempt from the Contractor's License Law for one of
inspection.
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
Signature of Applicant: Date:
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
[, as owner of the property, am exclusively contracting with licensed contractors to
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
instructthe project (Sec.7044, Business & Professions Code).
ereby affirm under penalty of perjury one of the following three
ie
HAZARDOUS MATERIALS DISCLOSURE
clarations:
I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self -insure for Worker's
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
Compensation, as provided for by Section 3700 of the Labor Code, for the
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
performance of the work for which this permit is issued.
Safety Code, Section 25532(a) should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided for by
Additionally, should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code, for the performance of the work for which this
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued.
maintain com liance with the Cup no Municipal Code, Chapter 9.12 and the
[ certify that in the performance of the work for which this permit is issued, I shall
Health &
AGENCY
I hereby affirm that there is a construction lending agency for the performance of "ork's
APPLICANT CERTIFICATION
for which this permit is issued (Sec. 3097, Civ C.)
I certify that 1 have read this application and state that the above information is
Lender's Name
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
Lender's Address
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
ARCHITECT'S DECLARATION
granting of this permit. ditiona yepp6 ant un stands and will comply
I understand my plans shall be used as public records.
with all non -point Section
9.18.
Licensed Professional
Signature
CITY OF CUPERTINO
FM-7 FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21710 SCB
DATE: 08/12/2011
REVIEWED BY: Traci
APN: 357-17-038
BP#: 11080092
'VALUATION:
1$4,500
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
USE.
PENTAMATION FURN/AC
PERMIT TYPE:
WORK
To Clear Code Enforcement Case: remove & replace existing HVAC unit
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY
UNITS
BP FEES
A/C Units (<=10K cfm)
1BCAIRHA
1
#
$130
TOTALS:
$130.00
Mech. Plan Check 1 1.01 hrs $130.00
f','r:rr,l, ,`l:,, ;•.,
IMECPLNC Mech. Permit Fee: IMPERMIT
P:o,, , PCI- it FL..
k r•
Lt'her Mech. Insp. 0.0 hrs $44.00
+ k r, r Phr+rfr 101;p.
c tq,yt .Ll
, L7.YFl, 1 Ere:
{'i!fl,f n. t1/Lt+, �'c'c':
F idr.'. ,rlf.+t7. rcc
NOTE. These fees are based on the areliminary Information available and are only an estimate. Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E '. 711/11)
FEE
QTYIFEE
MISC ITEMS
Plan ( beck
PME Plan Check:
$130.00
Pcrnzil FC(1.
,',/I 1. 1r7sp VC C
PME Unit Fee:
$130.00
PME Permit Fee:
$44.00
Con,strz!ction Tax
AIL oustwal Rol'icl1'
Work Without Permit? E) Yes 0 No
$304.00
p/awdinc FCC'S'
i
Travel Documentation Fee: IIRA VDOC
$44.00
Strone Motion Fee: IBSEISMICO
$0.95
0.5 hrs Admin./Clerical Fee
$41.00 IADMIN
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $653.951
$41.00 TOTAL FEE:
$694.95
Revised: 07/04/2011
CITY OF CUPERTINO
FM-7 FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 21710 stvns crk blvd.
DATE: 08/11/2011
REVIEWED BY: bobs.
APN:
BP#:
"VALUATION: 1$4,500
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
USE:
PENTAMATION FURN/AC
PERMIT TYPE:
WORK
remove and replace exising HVAC unit.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY
UNITS
BP FEES
A/C Units (<=10K cfm)
1BCAIRHA
1
#
$130
TOTALS:
$130.00
Mech. Plan Check 1.0 hrs $130.00
1MECPLNC Fmech. Permit Fee: 1MPERMIT
Other Mech. Insp. 0.0 hrs L$44.00
Li
NOTE: These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addh 7 info.
FEE ITEMS (Fee Resolution 11-053 EX 7/1111)
FEE
QTY/FEE
MISC ITEMS
pf,(101 Check h('e"
Sleppl. P 1'er
PME Plan Check:
$130.00
P(r nfif I, CC
Supp?, 1p?sp I Pv
PME Unit Fee:
$130.00
PME Permit Fee:
$44.00
,fcoitsricai Review
Work Without Permit? 0 Y s 0 No
$0.00
PPrrnning Fees.,
i
Travel Documentation Fee: ITRAVDOC
$44.00
Stronp- Motion Fee: 1BSEISMICo
$0.95
Select Administrative tem
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
1 $349.951
$0.00
TOTAL FEE:
$349.95
Revised: 07/04/2011