11080166CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19191 VALLCO PKWY I CONTRACTOR: ICOM MECHANICAL INC J PERMIT NO: 11080166 I
OWNER'S NAME: APPLE INC 1477 BURKE ST I DATE ISSUED: 10/05/2011 1
OWNER'S PHONE: 4089744876 1 SAN JOSE, CA 95112 1 PHONE NO: (408)792-2292 1
1:1 LICENSED CONTRACTOR'S DECLARATION
License Class, Li,. #
Contractor DatcLQ,
I 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
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 which may accrue against said City in consequence of the
granting of this permit. ditional %cant understands and will comply
with all non -point so icTnsp Cupertino Municipal Code, Section
9.18.
Signature Date
11 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (See.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.
BUILDING PERMIT INFO: BLDG 1— ELECT r PLUMB J_
*
MECH I r-RESIDENTIAL r— COMMERCIAL
JOB DESCRIPTION: REMOVE & REPLACE TWO(2) BOILERS AT MECHANICAL
ROOM
OFF LOADING DOCK
Sq. Ft Floor Area: I Valuation: $78000
APN Number: 31620074.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued b
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: - Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505,25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain c ,Qrpfiancew elthe Cupertino Municipal Code, Chapter 9.12 and the
� S
Health 4e�$dfety Qv c, S 6911p 25505, 25533, and 25534.
,9 T4!:,i �= ilT I I
140iWi
CONSTRUCTION LENDING AGENCY
I 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
ARCHITECT'S DECLARATION
Date
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FEE ESTIUATOP. - BUILDIV
ADDRESS: 19191 vallco pkwy.
DATE: 08/22/2011
REVIEWED BY: bobs.
rawtt
*PERMIT TYPE: Mechanical Permit
PLAN CHECK TYPE: Alteration Addition Repair
PRIMARY
Commercial Building
USE:
PENTAMATION M
ICMB6
PERIT TYPE: A
remove and replace 2 boilers at interior of buidling at mechanical room off loading dock.
Mech. Plan Check 13.0 1 hrs $390.00 .,whM`an Che-,,4
IMECPLNC
Mech. Permit Fee: IMPERAffT
El
Other Mech. Insp. 0.0 hrs $44.00 �!hoTbw
Fl 9
Wec,h", h
V e 0
IVUIE., I hese tees are hasea on the vretimmary intormatron avatiame ana are oniv an estimate (,intact tneueDt for aaawi into.
FEE ITEMS (Fee Resolution 11-053 Eff 7/11112
FEE
QTYIFEE
MISC ITEMS
Phan
PME Plan Check:
$390.00
Pcrrnif
, /P . A
PME Unit Fee:
$370.00
PME Permit Fee:
$44.00
("onstrach"(P7 KA
Work Without Permit? OYes No
$0.00
Travel Documentation Fee: 1 TPA VDOC
$44.00
Strong motion Fee:
IBSEISMCO
$16.38
F-6-5 --1 hrs
$41.00
Admin./Clerical Fee
]ADMIN
BUY, Stcls Commission Fee: IBCBSC
$4.00
77
JI Q A
$868.381
$41.00
TOTAL Z
01
$909.30