24224APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY
Building Project Identification -
FERMI NQ,
Building Address:
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IGSE-
'Owner
aNajmiL14 1_P ?4 �j.9G- one.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
APMCAUON SUBMITTAL DA in
1 1—CM
cdntm a•sN. .- .
ueNa:
NEAT
BUILDING-ELECTRICALPLUMBING-MECHANICAL
CATEGORY
CONTROLY
"
A its er.nif
Qtr , ELECTRIC PERINIT FEE'
- ` 'BUILDING P,ER,MIT_INFO
A Com%
❑ ❑
PERMIT ISSUANCE
LICENSED CONTRA OR'S DECLARATION
-,❑
-
I hereby affirm that am licensed under proviams m Chapter 9(commsee
ingwith Secdon7000)of Dlvitl=3ofthe BuWmmand feaalonsCode,andeny
Ilcenselsia:11 rceanddfect.
LI;I. Lic.
APPLIANCES -RESIDENTIAL
]OB DESCRIPTION
7 ��
PANELS
Da Contracto
201-1000 AMPS
ARCHITE DCLA D
I understand my plain shall used as pu
-
OVER 1000 AMPS
SQ. FT. F7.ODft AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional -
SPECIAL CIRC[RT/MLSC
-OWNER-BUILDER DECLARATION
I hereby affirmthat I am exempt from the Contractor's License Law for the
- -
TEMP METQ40R POLE INST.
following recon. (Section 70315, Business and Professions Code: Any city or
cmnty which requlree a permit to mmtmd, alter, lmpmve, demolish, or repair
any structure prior to is Issuance, also requires the applicant for such permit to
file a signed statement that he is, licensed pursuant to the provisions of the
t
POWER DEVICES
-
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3oftheBusaessand Prosslo
fensCods) or that he is exempt therefrom and
VALUATION ,
the basis for the alleged exemption. Any violation of Section 7033.5 by any
appliamt fees permit subjects the applicant to a civil penalty a not room than
-OUILETSSWITCHFS-FIXIIB?E@
five hundred dollars (SS(XB.
I, as owner of the property, or my employees with wages as their sale
NEW RESIDENTIALEL SQ.FT.
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is not Intended or offered for
'
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
-
does not apply to ae, owner of property who builds or improves thermq and
who dcea such work himself w th rough his own employees, provld W th at such
50C GROUP
RES.UMTS
Improvements are not Intended oroffered fwmis. If, however, thebulldingw
TOTAL:
Improvementbmldwilhinomyearofcompletb theowner-bu0derwfllhave
tfLIlurden of proving that he did not build or Improve for purpose ofmkJ.
LJ L as owner of the property, am exclusively contracting with licensed
mntredom to censtrod the Project (Sm. 7064, Business and Professions Code:
QTY, .,�. PLUMBINGPER FEE
FLCODZONE
APN ,
PERMIT ISSUANCE
The Contr.does License law does not apply to an owner of property who
WIWa or improves thereon, and who contracts for such projects with a
ctor(s) licensed pursuant to the Contradoe. License I.
cgRt[ew
L-1 I am exempt under 9e B & P C for this ream
ALTERGRAIN& VENT -
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF, AREA, CO
SANITARY -Y_ N_
RECEIPT If
Owner -Date
WORKMAN qOMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to self -Imre, ora
certificate o(Warkers'Comperuatlonlnsurance oracertifled copythereof (Sw.
380Q Lab CJ. l p _
CC/ /
pIXSpEXa
SCHOOL TAX Y_ N_
RECEIPT E `
GAS EA SYSTEM -1 INCA OUTLETS
PARK FEE Y_ N_
RECEI11r
Con, a
Com any ��l �%
GAS EA.SYSTEM-0VER4(FA)
BUILDING DIVISION FEES
[ Certl ed copy's hereby fis ebhed.
copy
hified copy b filed with the city Inspection division.
GREASE/INDUSTItL WASTE INTERCEPTOR
PLANCHGCK FEE
'
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need me be completed If the permit is for one hundred dollars
PAID
Date Recei t#
/
SEWER -SANITARY -STORM EA.200FI.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
($100)wlma')
I certify that in the performance of the work for which this permit is board,
WATER SYSTEM/TREATING
I shall not employ any person In any manner so as to became subject to the
Workers' Compensation Laws of Date
PAID
�1/69rna.
Applicant .Lf /--FF
NOTICE TO APPLICANT:ILa r ng this Certiflogeot Exemption,you
Date Recei t#
NEW RESIDENTIAL PLMB.SQ.FT.
TOTAL:
should Wourro ibjeette, the Workers' Compensation provisions ofthe Labor
Cods, you =at forthwith comply with such provisions orthb perut shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I
UI DI G E
!/%iL U E
SEISMIC FEE
Iherebyaffirmthat there Is a construction lendingagenry for the perform-
aemotthework for which t b permit's bsued(Sec. W97,CIv.C3
lander. a.
Lenders Address
Iwh(fythatlhavere thbappBcetionandctatethatlheaboveinformation
b carred ;I agree to corfplywith all city and county ordinances and gate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
�
QTY. > '•-'MECHANICAL PERMIT' ;;,. .. FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building ceruwdion, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, indemhily an d keep harmless the City of Cupertino
.,.lost llabllltles, judgermts,cost ... d expenses which may in any way.ecnre
ALTER OR ADD TO MECH.
Date Recei t#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL'
aga Inst said City In consequene, of the granting of this permit.
-
AIRHANDLINCUNIT (OVER IO,OWCFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date _
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BT U)
'
Date Recei t#
Willthe applicant orfuture building occupant store or hand le hazardous
material as defined by the Cu Nino Municipal Code, Chapter 9.12, and the
Hralthand SatetyC on 25532007
Ymof
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
❑
"-W ill theappllantor lure Wilding occupant usequipment or devices
which emit hazardous rconamr.rt..a defined by the Bay Area Air
Quality Management cat
❑ Yes No
A'
K
BOILER -COMP OHPOR 100,0(D BTU)
BOILER -COMP (OVER 100,000 BTU)
I M1ave read the haza Rua matedale requirements under Chapter 6.95 of
the California Health&Safety Code, Sections 25505,25533 and 25534. (-
understandthatlithebuilding dcea not currently have a tenant, that it Is my
responsibility to not occupantmo
lfy the occupant of the requirements which at be Ing,
.00T '7 1992
NEW RESIDENTIAL MECFI. SQFT
prior to Issuance ofaCehifi eof ccupaqu. I
/�14a./ L (. '
ISSUEDBY:
7/r 5r author a nt Date
TOTAL:
4 OFFICE COPY