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02080168m Idl ttM ❑1 osni rvr1 8pl � C� �$! �I 4 CITY OF CUPERTINO ^• >b� o-°:�*:,� x t C ,i BUILDING DIVISION PERS�C[?NTRACTORINF.ORMA N A o,. IHH!1P0b4Q0I3S19UBB RD TF MCGUCKIN INC PERMIT N92080168 OwUN14V9RSITY OF CALF. SANTA CR Z777 FOLSOM CR APPLICAT(918SJTG" 2002 HONE: (408)263-5614 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECORATION 1 hetet aRmn that I am licensed rad r provisions of Cha lar 9 commcncin 3 wifullto 71tl1crfCCL vision 3oftheBu fadPrafcuimuCapdc.andmylicenaew M)UI ' er1 tion TENANT IMPROVEE� 1�� p IIf m(ullmrec _ SEE TEMP PERMIT FOR SOME OF THE INSPECTIO 5 LIC C Lld.g n 020,.%0186 ARCHTIECCaRATION LAseJ I on raised my plain shall he usar as public mantis a Lkenacd Pmfessionsl OWNEm ON DE Ce RATContractors exempt E 1 hereby .form that 1 amBus m r an the C e: Any C Law for the > following mama. (Section 703". Bunters and oe: Any city m county - - Whleh e.Profession demolish, ally a1Nc1Um reCIirm 2 O the,pICc.Impmsuch Perittfirepair its isse8e,alsl apI,, Misa1ensed PMUAnir rce 111cisio or far ft Conector'lLicensle a LaedamtClncnl Sq. Ft. Floor Area 1356AQation (commencing with 7") of ofthenote donsCoprcr9 g (c 3 of Ne and PmfMy vi bald or 71and) xempt basis egad CUess . that k u exempt therefrom and Jte buu for the Alleged eacmption. My violation of l he is wndro JbAPWR be Occupancy Type . Section 7031.5 by any applicant for a permit subjecu the Applicant to a civil penally of not mom than five hundred dmlan(SW). ❑ I, As owner of Ne property, or my employee, with wages as their Aute compensation, - will do the Aust, and the uncture Isnot intended oroffemd for sahe (Sec. 70th, Businessand Professions Cade: The Contractors license Law date m squired Inspections not apply an owner of 102 - PIERS propenywho ere builds orimprnvm thereon, And mthrough d whodoesch work himselfor rough his Own employee, provided thw Inch improvements Amnon Intended mo0,read fornle. Ir, 103 — UFER however. the building or Improvement sold within one year ofcompletion, the owner 104 — REBAR builder will haw the burden of proving Nu M did not build or improve for purpose of ' Aale.k 105 - ANCHOR BOLTS - ❑Lasowneroflheprogeny, am exclusively contracting with Ecelaed contractors to lO6 — SEWER & WATER construct the project (Sec. 7046. 8mm ss and Professions Code:) The Contractor, Li conam LAW does red apply to an owner of propeny who leflift or improws, flaneom, and ' 202 - UNDERFLOOR PLUMBING who contracts for such Projects with a comn d pursuant the Cmuemi s mor(s) Rcenacun 203 — UNDERFLOOR MECHANICAL - Lkunelaw. ❑ 1 Am exempt under Sec. .B&P C far this rtssoA 204 - UNDERFLOOR FRAME Owner Date 205 - UNDERFLOOR INSULATION WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING I hereby affirm under penalty of perjury one of the following declarations: 302 — TUB be OR SHOWER I how And will maintain A eeruncam of Coment to self-insum ror Workees Comfort. 303 ROUGH MECHANICAL cation, u provided for by section 3700 of the labra code, for In performance or the — work for which this Immot is issued. 304 - ROUGH ELECTRICAL ❑ I haw and will maintain Workers Compensation Insurance, As required by Section 305 - FRAME 37M or the Labor Code, for the performance of Ne work for which this permit is issued. - MyWorker '��..��a.mn-�sallyn rmce trrcrand Polirynu hermt:f 306 - HOLDOWNS a'r:GLL3lLLU Paltry r 307 — INSULATION ceRfIPlcCo PENSATIONINSURANCEnONFR ORKER$' 308 - SHEETROCK (Thasection need nm becompicw lyda permitis mrone hundred dollars ($1011) 309 — EXTERIOR LATH 310 - INTERIOR LATH - I cenify that In the performance of the work for which this permit Is !wood, I shW not 311 - SCRATCH COAT ' employ any person in any mmncran as In become subject In the Wafter Compensation Laws .[California. Date 313 - ROOF NAIL 501 — FINAL ELECTRICAL ENERGY NOTICE TO APPWCANT.If, after making this Ccnificaw of Exemption. you should become Subject to the Workers Compensation provisions of the labor Code. YOU must ' 502 - FINAL PLUMBING ENERGY - forthwith comply with such provisions or this pelmitahall be deemed revoked. i + 503 - FINAL -MECHANICAL ENERGY CONSTRUCnON LENDING AGENCY I hereby arrim that them is a construction lending Agent' forthe Performance or 504 - FINAL BUILDING ENERGY the Work far which We permit is isoed(Sec. 3097. Ci, C.) 505 - FINAL ELECTRICAL Lenders Name Lender'sAaaree, 506 - GAS TEST 507 - FINAL PLUMBING IcertifythAt read thbtyApplication uWslatethe the Above information is oc1have Wilding agree coomtacomply wiled! city and county of and state la nunr upon to � builalne covwclion, And hereby euthonm rtprcxnunisv of this dlY bunter upon the the 5 FINAL MECHANICAL . i above-mentionedpmpeny for Inspection purposes, 09 - FIN DE (We) Agree m save, indemnify and keep h mnless the City of Cupertino against j liabilities. Judgments, case and expenses which may In my way accrue &aims said City r 5 N G ' r in consequence of the granting of this pCrmlL r APPLICANT UNDERSTANDS AND WI COMPLY WITH ALL ON -POINT t Issued by51 WORKS Date S URGE EGULA I S. Re -roofs Type of Roof 1 S a A plic Co t r- Date AZAR US MATERIAIS DISCLOSURE Will thea Aral or(uturc building occupannarom car henalc luvaNaus metedal As defined by Ne Cupertino Municipal Cudc, Chapter 9.12. and the Health and Safely - Coa,.3cation 25532(a)? ❑Yes MI. 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 Will the applicant or future building occupant use equipment or devices which mit hassrdous air contaminants as defrnca by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes Nu I haw mad the huvardnus materlelsmquimmena under Chapter 6.95ofthe Califor- niaHcalth&Sdcty Code.Sectinm25505,25533md25536. lundcrslmd Natirdm building docs not currently have a tenant, that it u my responsibility to notify the WCUpant r dte req ire Ana len muAt be mel poor to !scam df. Ce aw or mu smeey. � F&L Signature of Applicant Date All roof coverings to be Class "B":or better ho ownimhoam ag t Dine OCT -15-2002 11:14 MARK THOMASiCIJP 4082535173 P.01i01 CUPER*O SANITARY DISTRICT 20065 Stevens Creek Blvd., Bldg. C J DER: Cupertino, California 95014 CHB: (408) 236.7071 CV: File: dbmunity Development Department - Building�yI �, ZOO f Cupertino Date; WL 10300 Torre Ave. File: CuSD • MOP Cupertino, CA 95014-32D2 City of Cupertino Re: Subject: � Name: L_LAD,,pN Cr +t U i 0%'7� Addrvsa: 2)12 Duct Alvl� APN: 075 _,+2 - 064 Control/Plan Ck No: Permit No: The Cupertino Sanitary District has reviewed the plans for the subject project: No additional conditions/re4uiremznts bythe Distrix. h r' PIZ4 9 fo F44'r11q&/ rL1UM64N6r PSI l D Sanitary' sewer is available and the existing building is connected to Sanitary sewer. see conditions/requirements listed below. Ci Sanitary sewer is (not) available, see conditions/rcquiremenls listed below. ❑ Sanitary seweris not provided by The Dis:ricr, picric contact the City of3unnyvalo.t?a (4081750-7910- The 4,p$j7gp-7910. The following Conditions/Requimments are made: • 0 instail.new Property Line cleanout or locate and raise to grade an existing property line cleanout. Cleanout shall be the same diameter a5 the street portion of the service lateral (Minimum gravity lateral is 4" diameter). Videotape inspection of the existing Cleanout, Point of Connexion and Street Lateral is required Please Do Not Inspect any onsite construction until this is cleared in writing by the District, Owner to call District 48 hours prior to video inspection to schedule a Distrix Inspector, ❑ Sewage Pump is required, unless Civil Engineer certifies that the lowest finished floor with plumbing is at least one (1') foot above the rim of the next upstream manhole prior to issuing a Cupertino Sanitary District Connection Pemtit. ED Cupertino Sanitary District Fees or Permits are required for the subject improvemertits please do not issue any building permits. ❑ Plans shall be reviewed by'the Industrial Waste Division of the San Jose /Santa Clara Water Pollution Control Plant, Phone ei4G..6jj7 1 943-3699 for questions and to schedule an plan appointment. Please Do Not Issue permits until pretreatment rccommrnna dtuiof�� have been forwarded to ,you by the District. ❑ Verify existence and serviceability of an existing backflow protective device. Break areas authorized minor ulccuical appliances only. (No commercial disposal or commercial dishwasher installations.) ❑ Other:... Storm water from surface or roof drains, other general surface runoff water or condensate from any residential HVAC equipment shall not be discharged to the sanitary sewer. NOTE: Contact CuSD for "OFF-SITE REQUIREMENTS" C¢+IN vii 'ile. Building Letter tcv. 02/02 TOTAL P.O1 • City of Cupertino Plan Check Transmittal • Permit# Project Address Owner 02080168 Control# 11395 Plancheck# 3 FileDate 8/29/02 TENANT IMPROVEMEN 10420 BUBB ROAD UNIV OF CALIF EXT Description 3 Plan Check Status (attach comments and return to Building with plan set) Dept Plan check# Date Due Date Staff Comment Date Approval? Building 3 10/16/02 10/23/02 BRUCE 11 Planning 3 10/16/02 10/23/02 PETER n Fire 3 10/16/02 10/23/02 mark /D WIPo Sanitary 3 10/16/02 10/23/02 CARL CIJ Assessor 3 10/16/02 LI Housing Mitigation Fee Amount Heart of the City Specific Plan Fee Amount 0 10/23/02 Housing Mitigation Fee Amount Heart of the City Specific Plan Fee Amount 0 OCT -10-2002 11:01 MARK THOMAS CUP 4082535173 P.01i01 t_UYG llVIJ JtllVllHrti L1J illi<.1 24W Stevens Creek Blvd.. Bldg. C VDER: Cupertino, California 95014 ✓ GM - (408) 253-7071 CV:/ File: . `40N -STYE REQU=NaNTS-OVER THE COUNTER RE. �y/r(t�"r t/ t Dam: l%'C/1 O� Z 041 7e) File: CuSD-MOP Building Depr•Cupertino Community Development Department . Building City of cupertino 10300 Torre Ave. Cupertino, CA 95014-3202 Re: Subect:1t44t`7,`M,ttV-r N IPV'V�T/'"vt'� , Name:.(Amv (�T� N -fdlh. �i ION ,address: 1047,0 $U 8f� l D APN. 357- 20- 0:36 ContruVPlan CkNo: 1 I "2 J1 Permit No: o20&1 �S . the Cupertino Sanitary District has reviewed the plans for the subject project: No additional conditionstrequircmenta by the District. OwN6t: 014PLiSl7 Ki LTi{ T+:� 0 Sanitary sewer is available and the existing building is connected to sanitary sewcr, see conditions/requirements listed below. 0 Sanitary sewer is (nor) available, see conditionsrrcquircments listed below. • 0 Sanitvey sewer is nor provided by the District, picas: contact the City of Sunnyvale. The. following Conditioits/Rcgpirements are made: 0 Install new Property Line cleanout or locare and raise To grade an existing property line cleanout Cleanout shall be the same diamer_r. as the street portion ofthe scr%ice lateral (,Minimum gravity lateral is 4" diameter;. Videotape inspection of the egisting Cleanout Point of Connection and Street Lateral is required, Please Do Nor Inspect any cosite construction until this is cleared in writing by the District, Owner u) call District 49 hours prior to video inspection to schedule a District Inspector. 0 Sewage Pump is required, unless Civil L• agineer certifies that the lowest finished floor with plumbing is at least one (1') four above the rim of the newt upstream manhole prior to issuing a Cupertino Sanitay District Connection Permit 0 Cupertino Sanitary District Fees or Permits are required for the subject improvernatts please do not issue any building permits. 0 Plans shall be reviowcd by the industrial Waste Divisinn of the San Jost /Sant Clara WaterPollution Control Plant Phone 945-3000 for questions and to seheduie ar plan appointment. Please Do Nor issue permits until pretrcatment recommendations have born forwarded to you by the District. 0 Verify existence and serviceability of an existing backflow protective deviec. u Break wens authorized minor electrical appliances only. (No commercial disposal.or commercial dishwasher installations). 0 Other: ........ :............... .............................................. ............. ............................................. -........................................ water from surface or roof drains. ofncr general surface runoff water or condensate from any residential HVAC equipment shall not nhartted to the salutary sewer. VOTE- C--t-gCs'-,,CD fnr rr(1FF-_CTTli. R�Ti'OT1i—ile M:MENTS" Vl. c%ttlEN Vi" - TOTAL P.01 S�tPpLARA c�G w I a.A CODE/SEC. I SHEET I NO. I REQUIREMENT II~ IIRAEPAR'H'MlENT SANTA CLARA COUNTY PLAN RES No. O 2 2 19 7 BLDG PERMIT No. 02080168 14700 Winchester Blvd., Los Gatos, CA 95032-1818 395 (408) 378-4010 • (408) 378-9342 (fax) • www.sccfd.org CONTROL No. PLAN REVIEW COMMENTS of revised plans for a proposed tenant improvement. comments 1 - 3 have been addressed. • Approved: Okay to issue applicable permits City PLANS SPECS NEW RMOL AS OCCUPANCY CONST. TYPE ApplluntNpma DATE PAGE CUP ® ❑ ❑ N ❑ B III - N Wayne Renshaw Architect 10/3/2002 1 1 OF SECJFLOOR AREA LOAD DESCRIPTION BY 6,723 sf Commercial Construction Barnes, George NAME OF PROJECT LOCATION NIVERSITY OF SANTA CRUZ EXTENSION 10420 Bubb Rd Organized as the Santa Clara County Central Fire Protection District Serving Santa Clara County and the communities of Campbell, Cupertino, Los Altos, Los Altos Hills, Los Gatos, Monte Sereno, Morgan Hill, and Saratoga CITY O CUPERT#1NO W. b CITY OF CUPERTINO o2 o PERMIT APPLICATION FORM AP # r`D --01W !► Date: Fee Group , Buildin Address: Owner's Name: 11% Phone #: 2 BUILDING Contractor: License #: T! HedcX40. Contact: BCONSTA)MQ Phone #: WAP01W Wov 40K Applic a� Fax #: BCONSTAXR Constax — Resi/Mobile ing Permit Info:' Bld ✓ Elect ✓ ;Plumb 40% Mech)OIL,-- ✓ Job Job escription: / / �- esidential: yCOAC cial: Sq.Ft. Floor Area: W ISPP $/Sq•F , v0 Architect/Engineer:: Valuation: IAAL, `G/v ype of Construction: Occu ancy Group: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTA)MQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <-- 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <-- 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BNEWMULTI New Multi -family Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM I New Comm Mechanical MECHANICAL BNUCOMMP I New Comm Plumb PLUMBING 1 of 3 0 4 CITY OF CUPERTINO c"or CUPEI�TINO PERMIT APPLICATION FORM • uanti Fee ID Fee Descri tion Fee Group BNUMULTI New Multi -family Res PLUMBING. BOVERTIME Ins action Overtime BUILDING 13PBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cess ool PLUMBING BPERMFEE Bid Permit Fees BUILDING BPFIXTURE Pbl Fixture PLUMBING BPGAS Gas Pi in S stem Fee PLUMBING BPINTERCEP Ind Waste Interc for PLUMBING BPL CHK Plan Check Fee BUILDING PLANCKADD Plan Check Add Multi BUILDING BPLANCKREP I Plan Check Repeat Fee BUILDING BPREPIPE R i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklermackfl0 PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen TranPLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER InstalUAlter Water Pi a PLUMBING BPWHEATER WaterHeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reins ection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL BREMAPPLI A liance Install MECHANICAL BREMBUSWAY Remodel Buswa s ELECTRICAL (O BREMFIXT Li htin Fixtures ELECTRICAL BREMFURN Relocation ofFurnace MECHANICAL 13REMFURNOV Relo Furnace > 10K btu MECHANICAL BREMHEAT Heater Installation MECHANICAL 13REMINHOOD Installation of Hood MECHANICAL BREMMISC Misc A aratus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER BREMRECEPT PowerDevice/A aratus ELECTRICAL Re tl Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Re air/Alter Heatin MECHANICAL BREMRESAPP Remodel Res A liance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS I Remodel Signs, Mar uee ELECTRICAL BREMTHEATR I Theatrical Li tin Fix ELECTRICAL 2of3 CITY OF CUPERTINO CITY F PERMIT APPLICATION FORINT • CUPERTINO ua Fee ID Fee Description Fee Group BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING ' BSF&2FAM Sin' le & 2 Family BUILDING BSFNA Single Family New Add BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler > 1.75 M Btu MECHANICAL • 3 of 3 I .I CITY OF CUPERTWO' BUILDING DIVISION PERMIT CQNTRACTOR.INFORMATION: aw1.D0l4,2h0FSUBB RD TF MCGUCKIN INC PERMITNO2 08 0 16 8 NIVERSITY OF CALF. SANTA CR Z777 FOLSOM CR APPLICAT®`81J'k TY2002 PIIONE: (408)263-5614 SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH O O O O LICENSED CONTRACTOR'S DECLARATION I hereby affirm thollam license)yndgr prnvinonsof Chapter 9(commencing with Sectiyp 79ay�f Division 3 of the Bu1��F! end Prufessinna Cade.and my licerac is 'TENANT IMPROVE'�RM1Q�1'erlp[I0n in full force dellen. SEE TEMP PERMIT F�.SPME OF THE INSPECTIO Liamnscc Con' m Con' 02070186 P11MALED A IC LARATION , all the 1 and island my plans shall M used as public records NOV 2 7 M2 Licensed Pmfcssional OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county BUILDING which requires a permit to construct, altar. improve demolish. or repair any structure prior In its issuance, also me, intax the applici m for such permit m file a signed anti mens that he is licensed pursuant to tha provisionsofdte Contractor's License law(Chaplar9 Sq. Ft. Floor Area $1356'@Qation (commencing withSection 7f1t1(q of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged cxemrrtino An, violation of beU Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of not more Nen lout hundred dollars ($500). ❑ I, al owner ofthe property, or my employee with wages at their sole compensation, will do the work, and the StNetnR IS net Intended or Offered for sale (Sec. 7044. Business and Professions Code; The Comment's License Law does not apply to an owner or iei equired Inspections 102 - PIERS property who builds or improves thereon, and who does such work himself orthrough his own employee, provided that such improvements an: not intended oroffered foraale. If. 103 — UFER however. the building or improvement is said within one your o(completion. the owner. 104 — REBAR builder will have the burden of proving that he did not build or improve for purpose of sale.). 105 - ANCHOR BOLTS ❑1, as owner of the property, am exclusively contracting with licensed contractors to 106 - SEWER & WATER construct the project (Sec. 7010, Business and Professions Code:) The Contractor's Li- censelawdoesnotapplytoanownerofpropenywhobuildaorimprowsthemon.and, 202 — UNDERFLOOR PLUMBING contracts for such pmjecu with aconuutor(O licensed pursuant o dm Comrecm`1 203 - UNDERFLOOR MECHANICAL Lwho icense Low ❑ l am exempt under Sec. ,B&P C for this moon 204 - UNDERFLOOR FRAME Data 205 - UNDERFLOOR INSULATION Par WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING I hereby affirm under penalty of perjury one of the following decimations: 302 — TUB & OR SHOWER - ❑ I have and will maintain a Certificate ofconscnt to self -intim forworkers Compen. 3O3 — ROUGH MECHANICAL ation, a provided for by Section 3700 of the Labor Code. for the performance of the work for which this permit fa issued. 304 - ROUGH ELECTRICAL ❑ I have and will maintain Workers Compensation Insurance, a required by Section 3 05 - FRAME 37(X) of the Labor Code, for the performance of the work for which this permit is issued. My Worker' nm nse0i sumnce Diet and Policy no her are: 306 — HOLDOWNS a �Patio'F . 307 - INSULATION CERTIfICATEOFEXEMPTIONFR MWORKERS' —,03-308 COMPENSATION INSURANCE - SHEETROCK (Thissecnionneed not M completed lithe permilisforenchundreddollars(SIOD) 309 - EXTERIOR LATH less') 310 - INTERIOR LATH 1 certify that in the performance of the work for which this permit is issued, l shall not 311 - SCRATCH COAT employ any person in any manner an m it) IMcnme subjectan the Workcrs' Compercalion Laws of California. Dale 313 - ROOF NAIL Applicant 501 - FINAL ELECTRICAL ENERGY NOTICE TO APPLICANT: If, after making this Cenifcate of Exemption, you should become subject to the Worker's Compensation provisions of the Ulan Code. you must 502 - FINAL PLUMBING ENERGY forthwith comply with such provisions our this permit start be deemed revoked. 503 - FINAL MECHANICAL ENERGY CONSTRUCTION LENDING AGENCY Iherehy eRrm Nn there iso aomwctien lending agco¢Y En the performarrcc of 504 - FINAL BUILDING ENERGY the work for which Nis permit is issued (See. 3097, Civ, C.) Lender's No 505 506 507 - FINAL ELECTRICAL - GAS TEST - FINAL PLUMBING n% Lender's Address I have real and that the shave information Is I LCnee rating to comply withal) city and county ordinances and statelawseupong Its building o c Deity and coup dine 5 FINAL MECHANICAL building coawctien, and hereby awhomn represematiwa of his city to enter upon Nc constr ahow-mentioned property for inspection purposes. O9 — FIN DE (��J (WC) agree to save, indemnify and keep harmless the City of Cupertino against City 5 habildics, judgments, costs and expenses which may in any way seine against said in conacquence of the granting of this permit. APPLICANT UNDERSTANDS AND WI COMPLY WITH ALL ON -POINT Issued by`il 1 N N G WORKS Date S URCE EGULA I S. Re -roofs S rico A plic Cn n r Da¢ IA2AR US MATERIALS DISCLOSURE Type of Roof Will thea am in future building occupant rare or handle haudotu material as defined by the Correction Municipal Code, Chapter 9.12, and the Health and Safety 1e.yes ss3z(a)7 Yes 0KN 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 Will the applicant or future building mcupa d use equipment ordevieca which emit hazardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection. Dislrierl ❑Yes No [haw real Ne hamrdous materialemquimments under ChapmrR 95 of the Califor- nixHealth&Safeoy Clde,Sccuoa25505,25533and25534. IunderRendnhaifthe building docs not currently haw a tenons, Na it is my repoaibilily w he ly tbe occupant I'the req ire cots ich must he met prior to issuan orate am or— ay Signature of Applicant Date All roof coverings to be Class "B" or better own ro anthori c ag t Date Y