23276 (2) 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