11060182 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22601 VOSS AVE CONTRACTOR:MT2 TELECOM,LLP PERMIT NO: 11060182
OWNER'S NAME: CITY OF CUPERTINO 3780 COMMERCE DR DATE ISSUED:06/21/2011
OWNER'S PHONE: 4087773221 W SACRAMENTO,CA 95691 PHONE NO:(916)376-8555
Ci LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# _f :� I
MECH r RESIDENTIAL COMMERCIAL
Contractors ,� c' C� '�i� j Date G i
JOB DESCRIPTION:INSTALL METER PANEL&ASSOICATED CONDUIT ON
I hereby affirm that I am licensed under the provisions of Chapter 9
EXISTING PG&E POLE
(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 declaration
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 Sq.Ft Floor Area: Valuation:$5000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:34215038.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per. a Cupertino Municipal Code,Section „( G,
9.18. / Issued by:
Date:
Signature Date
[ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
ALL ROOF COVERINGS TO BE CLASS"A”OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505 25533,and 25534.
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,1 Own i or a�tofl int: -- / /, l
[
become subject to the Worker's Compensation provisions of the Labor Code,I must Date: t� /
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
c- and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
g of this permit.Additionally,the applicant understands and will comply
wim all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 22601 voss ave. DATE: 06/21/2011 REVIEWED BY:
APN: BP#: "VALUATION: $5,000
'PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY —FP—EN 1 REAP2
USE: SFD or Duplex PERMIT TYPE:
WORK install meter panel and associated conduit on exisitn e. pole
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 100 Amps $42
TOTALS: $42.00
Elec.Plan Check 0.0 hrs $0.00
Elec.Permit Fee: IEPERMIT
Other Elec.Insp. 0.0 hrs $42.00
NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fire Resolution 09-051 Lf 1.-10) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $42.00
PME Permit Fee: $42.00
Work Without Permit? 0 Yes E) No $0.00
Travel Documentation Fee: IIRA VDOC $42.00
Strong Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee
Bldg Stds Commission Fee: IBCBSC $1.00 $39.00 ]ADMIN
SUBTOTALS: $127.50 $39.00 TOTAL FEE: $166.50
Revised: 04/29/2011