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23276 APPLICANT TO FILL IN INFORMATION WITHIN RED LINE — POINT PEN ONLY D BuildingProen Identification _ FERMI TNO.23276 Bwiahg Aearee,: errs ane: - one: n . CITY OF CUPERTINO-BUILDINGDIVISION sent r'eNa LIc.N. APPLICATION I PERMIT BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL N rciaitect/Enginaen Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address Pf]iMRTISSUANCE U I PLUMB MUCH 1:1 1:1 ❑ LICENSED CONTRACTOR'S DECLARATION -thatlamlicensed under provisions fhrm APP[dANCESRESfDENTUL IQB DESCRIPTIONingwithSeon7O00)afDioftheBuslnuandProfNmaCode,and hoc.salainfib died. 5 ,S PANELS ,../mss' ✓��/7///A�/` License Cla Llep or Date Contractor UP TO 2DDAMPS RCHITEO ECU 10 201-1000AMP5 < Iundentand my puns slurs be used upubllcrecoNs. OVER 1000 AMIs5 g - FI' ARQ. 5/SQ.FT. Q�u 00 r1, 16J1 Licensed Professional dddd OWNER-BUILDER DECLARATION T R Ci SI'ECIALCItCU[T/MIST Thereby a((lnnthatlam ezemptfromthe Contractola License Law for the K4iqqfollowing reason.(Section 70315,Business and Pro&sslnns Code:Any city or /} cy counlywhichrequlmapermittommtmd,alkr,Impmve,demhsh,orrepair T�P.ME[ER ORIOLE INSF. O 7 q`'0 3 anystructure priorly its Issuance,also requlmtheapplimet forsuch permit to F file a signed statement that he Is licensed pursuant to the proviaWns of the POWER DEVICES 3 u.� Contnnara License Law(Chapter 9(commencing with Section 70X10)of Divi- SWIMMING POOL ELECTRICVALUON 1„405 slon3ofthe 8usinmsand lhofeeekna Code)orlhrt hsbeumpltherefromand VALUATION g 0 the bash for the alleged exemption. Any iviolation dvi of Benyon na by any OU LETSSWITCHESFIXTURFS appbasis for apermited exemption. Any toanull pemkyo703 .5 by any `J live hundred dollars(5500). �n ❑f,as owner of the m NEW RESIDENTIAL FIECTR SQIT. RIIS TYPE CONSTRUCTION property,or he employees with wages ore their sole compensation,BuMmwillciothework,andthes Code:Thn ontendedractor License Law solO dor(Set 7064,to anow aeWf property Cobuild,or Impctota Llceaae Law S who odrs oassuch apply tomowner ofproughNson employees,provided con,that and �^ whodcesauch work hlmseUmthreugh Msownemployees,provWedthatsuch OCC.GROUP RFS UNITS Improvements arc not Intended oroffered for sale.If,however,the building or TOTAL: Improvement hsokl within oneyearofcompinion,the owner-builderwiil have tlrk)(urdenofpmvingthat he did not build or Improve for purpose ofsahJ. QTy. PLUMBING PERMIT FEE FLOOD ZONE APN LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to commact the project(Sec.7014 Business and Professktu Code: The Contractor's License Law does nal apply to an owner of property who hullde or Improves thereon,and who commons for such pPjMs with a ALTER-DRAIN&VENT•WATER(EA) m,)g(anor(s)licensed pursuant to the Contranora License Law. FEE SUMMARY I_l I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y N • Owner Dale RFLEf N WORKMAN COMPENSATION DECLARATION FDCrURES PER TRAP SCHOOL TAX Y N ❑I hereby af(Irm that I have a ceniBcete of consent to self-Neurc,or RECEIVE N reninateofWorkers'Compesuationlmunnce ora certified copy thereof(Sec. GAS EA.SYSTEM-1 INC4 OUTLETS PARK ITE Y N 3800,Uib CI /� - — PolkyN fi�G/'!/D7�a'3 GAS EA.SYSTEM-0VER4(U) RECEIPT# Cnmoanv_��_/,�1� I RL BUILDING DIVISION FEES ❑seen cupcopy is fed with the city V GREASE/INOUSIRL WASTE INTERCEPTOR PLANCHECKFEE rtlned copy h nerd with the ctty Irupectlon dlWtlan. CERTIFICATE OF E(hMPTION FROM WOR KERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWM&ANTTARY-STORM EA.200FL. Date Rewi t# (This section need net be completed if the permit Is for one hundred dollars ($100)or leu.) WATER HEATER w/VENT/ELECTR ENERGYFEE Y N I comfy that in the perfarmance of the work forwhlch this permit is Issued, — I shall not employ any person in any trouser se,u to become subject to the WATER SYSTEM/TREATING Workeri Compensation laws of Cal fomia.Data PAID O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recet t# Z NOIICETO APPLICANT.If,after making this Certificate of Exemption,you should become subject to the Worken'Compvuation provisions of the Labor TOTAL: it T Code,you mu at forthwith comply with such provisions orMh permit shall be BUILDING FEE �w W 9 deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 1 herebyaffirm that them is a construction lending agency for the perform- ELECTRIC FEE M Z an of the work for which this permit is Issued(Sm 3097,Civ.C.) TOTAL: V O Iandele Name PLUMBING FEE LL Iandea's Add mse QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Icertlfythatl have read thhspplicitionand statethattheabove Information 6 iecorect,I agmto complywithW city and county ordinances and pate law, PERMIT ISSUANCE FEES PAID: >. relating to building construction,and hereby authorize repomentatives of this (,.. to city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. ? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# V against liabilitln,'ydgments,consand expense,which may In anyway acme AIR HANDLING UNIT(TO 10,010 CFM) SUBTOTAL: aga Wt said City In consequence of the granting of this permit. AIR HANDLING!INR(OVER 10,000CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Data 2(HAOSTHO0D(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building pant to re or handle hazardous HFATINGUMTOOI00,000BTU) Date Recei t material as defined by the Cupertim Nctpal Code,Chapler9.12 and the llealthand Safety Cade Sect 32W) HEATING UNIT(OVER 100,000 BTU) TOTAL: Yec o illtheappilcant or future building ocev fit use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUAWEIDATE which emit haaurdousalr con/amim enned by lM gay Area Air . llty Management District? BOILER-COMP OHPOR 100,000 BTU) Yrs orr ahavc read lhehaza onsaterhals requlrcments under Chapter G95 of BOILER-COMP(OVER 100,000 BTU) OCT) 22 �2o the Californla Health&Safety Code,Sect Ions 25505,2M3 and 75534.1 _ underat�that lithe building does not currently have a tenant,that it is my building does not curmnUy have a tenant,that it b my NEW RESIDENTIAL MEIN. SQI7- CITY Uh CUrtnlinU apo b ancenor Cerie,occu 0 there ulrementa�c�must be met prior o suance aCertl aprlor o a Occvpa� neror authorised agent TOTAL: ISSUEDBY:�� • OFFICE COPY