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02120077X00 �U OZ=- �3s a� w—w !gp9-Zt uai�S Oz z0 a� CY Q �z UO OF �fat a U a� CITY OF CUPERTINO BUIL PERMIT "'� CONTRACTOR INFORMATION: nwLDINGADDRESS: SOUTH BAY CONSTRUCTION CO PF&1'rNo. 20450 STEVENS CREEK BLVD 02120077 NAME: 511 DIVISION STREET APPLICATION SUB DATE CR'S ONEXANT SYSTEM, INC. 12/18/2002 PDONL. (408)379-0400 SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR Of CON I MrcM1y off that I am license,] under provisions of Chapter Y (commencing ScniO 7aX f Sof Prolessuno Code.sual iccnacis Job Description p wish sinew an mmLt.E, ant `" % TENANT IMPRVOEMENT FINALE® D c ComaanrKAII A H=S- R undcrsmnd my plans shall w used as PuMie rccnNs FEB 1 8 2003 Lieensed Professional OWNER BUILDER DECLARATION I herchy affirm that 1 am exempt from the Contractor's License Law for the BUILDING lowing son. (Section 7031.5. Business and Professions Code: Any city or county l idrco which rcy Ives a Penht to construe, alter, improve, demolish, nr repair any mructure prior m its issuance, also requires the applicant lou such permit in file a signed smument that be is licensed pursuant 0 the provisions ofthe Conuamm's License law(Chapfer9 Sq. Ft. Floor Area $67VZ&tion (commencing with Section 70flB) of Division 3 Of the Business and Professions Code) ter that he is exempt therefrom and the basis for the alleged exemption. Any violation of (OGGn Occupancy Type Section 7031.5 by any applicant for a Permit subjects also applicant o a civil penalty ofanC not moa than five hundred dollars ($500). I, m owner of the property, or my employees with wages as their sole comperrounion, will do the work. and the structure is not intended or offered for aide (gee. 70]4, Business Professions Code: The Communes LicerXu Law docs equtred Inspections and not apply to an owner of 102 - PIERS property who buildsor improves thereon, and who doessuch work himuHor through his own employees, provided that such improvements arc not intended oroUcred for We. If. 103 — UFER howeveq It building or improvement is sold within one year of completion, she owner - 104 - REBAR builder will have the burden of proving that he did not build or impron for purpose of sai1e) 105 - ANCHOR BOLTS ❑ I, as owner of the Properly, am exclusively contracting with licensed contractors to 106 - SEWER & WATER consumer the project (Sec. 7044, Business and Professions Code) The Contractors Li. cense Law does not apply to an owner of properly who wads or improves thereon, and 202 — UNDERFLOOR PLUMBING who commcu for such projects with a contractor(a) licensed pursuant to the Contractor's License Law. 203 - UNDERFLOOR MECHANICAL ❑ 1omexempt uad,,Sec. ,B&PC for this ..on 204 - UNDERFLOOR FRAME ser Date 205 --UNDERFLOOR INSULATION WORKER'S COMPENSATIONDECLARATION 301 - ROUGH PLUMBING I hereby a0irm under penury of perjury one of the following deelaredons: 3O2 — TUB & OR SHOWER ❑ I haw and will maintain i CeniOcam of Cem mmto self-insum for Workei sCompcn- othien, as provided for by Section 3701 of the Lahr Code, for the performance of the 3 03 - ROUGH MECHANICAL work for whichmiapermivaissued, 304 - ROUGH ELECTRICAL ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3 05 - FRAME 3700 of the Labor Code, for tw performance of the work for which this permit is issued. r m' ��D My Worker' mprormom lnsumnce carrlerand Policy nuMES 306 - HOLDOWNS Carrier. LI wtfieyNn: ES 307 - INSULATION CERTIFICATE OF EXEMPf10N FR W �f_ COMPENSATION INSURANCE /—i 308 - SHEETROCK Thissection madnot bccompdmed iftM permit isforone hundreddollars(SIM) 309 - EXTERIOR LATH 1f 1cs7 310 - INTERIOR LATH 1 cenify that in the pearan once, or on, weak far which this permit is issued, 1 shall not 311 - SCRATCH COAT employ any period in any manner m as to become scuit" m the Workers' Compensation Laws of Colifomia. Dau 313 501 - ROOF NAIL - FINAL ELECTRICAL ENERGY ApplicaNOTICE NOTICE TO APPLICANT: IL ease making this of Exemption, y oushomd visions of of theLaborrCode, you must Mchwithcompect roit Worker's Coons 502 - FINAL PLUMBING ENERGY forthwith comply with such provisions or this Permit shall w deemed revoked. or this Permit 503 - FINAL MECHANICAL ENERGY CONSTRUCTION LENDING AGENCY I hereby affirm Nat there is a conswction lending agency lir the Perfamaneeor 504 - FINAL BUILDING ENERGY r which this permit is issued (S. 30)7, Cie C.) thework faec the workdeA Name 505 506 - FINAL ELECTRICAL - GAS TEST Lender's Address 1 cenily Net I have read this application and state that the above nomination is 507 - FINAL PLUMBING correct. I agree to comply with all city and county Ordinances and stale laws raising to hembyaWM1odaerposesenativcs of this city to enter upon the huive-mentioned 5 roend aMrvomeminncJ property fnrimPccuon purposes. O9(Wc) agree to care. indemnify and keep harmless rhe City of Cuperlino againstliabilities,judgments. ensu and expenses which may in any way accre against aid City 5WMECHAMNIWCAL WFINAL of on, granting Of in his APPLCANTeUNDERSTANDStAND W r L COMPLY WITII AL NON -POINT Issued by51RKS Date SO ULATIONS. -I8-0 Re -roofs Type of Roof pPlicaHAZAndsComatid RDOUS MATERIALS DISCLOSURE Dau Will that aPPRUM or future building occupant stare or handle hazardous material defined by the Cupertino Municipal Code, Chapter 9.12, and the I Iealth and Safety 25532(b?' m,Yes All roofs shall be inspected to any roofing material being installed. 0Yes �o prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or futurea building use or devices which by The B emit ict? i air conaminana as defined by The Bay Arca Air Quality Management Area Air u all new materials for inspection. District? ❑Yes lhawreadthehvardo smawdalsmquircmenuundcr Chapur6.95ofNCCalifor- aiallealth&Safety Code.Stttivas 25505,255 JanJ 13511.1 understanJ Nvif Ne building does net currently haw a mnanr, Nar it 6 m respensihiliry w notify clue occupant orthe rcqui ewd hiehmust wmet pdnr I ancenr�nieea era paney/9 Signature of Applicant Date All roof coverings to he Class "B" or better On thori,edagent Date p00 <O<Z�Z 60'U yya� U..03 �u�p0 cRa tit^re C�6 65$ OD N WQ az UO 0Ur. U w U CITY OF CUPERTINO.. "' ..'• , v5a 3 Y BUILDING DIVISION p _ IT � CONTRACTOR INFO ATTON '. BUILDINGADDRESS: SOUTH BAY CONSTRUCTION CO McITNO, 20450 STEVENS CREEK BLVD 02120077 OWNER'S NAME: 511 DIVISION STREET APPLICATION SUB DATE CONEXANT SYSTEM, INC. 12/18/2002 PHONE: (408)379-0400 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSEDCONmed..d CONTRACTOR'S DECLARATION 1 hereby aff that 1 am licensed under proviaiom of Chapter 9 (commencing IChap wiNSectio 7 of "' Sof ineaan Pmfcssionsemde.amda Job Description p censeis imm�mrcea License CI ic.I _ D c ConVedmr TENANT IMPRVOEMENT �iN lo 1` A HITELTS R ` j understand my plans shall be used a on lic records �/O Licensed Pmfcssional OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractors License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a Penn, to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed atamment that he is licensed pursuant o me provisions ufth. Connemara License Law (Chapter 9 Sq. Ft. Floor Area $67>iYAG9tlon (commencing with Section 7") of Division 3 of me Business and Professions Code) or Oat he is exempt therefrom and me buffs for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit aubjects me applicant to a civil penally of not mom than five hundred doBara (SSW). Occupancy Type ❑ I, as owner of the property. or my employees will, wages u their sole compensation, will do the work. red me structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Comzmlor's License Law does not apply to an owner of 102 egwre - P I ERS d Inspections pmperty who builds or heroines thereon, and who does such work himself or through his . own employee, provided that such improvements are not intended or offered for ale. If, 103 — UFER however, me building or imprevement is sold within one year of completion, me owner builder have 104 - REBAR will the burden of proving mat he did not Wild or improve for purpose of sale.)_ 105 - ANCHOR BOLTS E] 1, as owner of the property, am exclusively contracting with licensed convecmn to 106 - SEWER & WATER construct the project (Sec. 7044, Business and Profusions Code:) The Conlradars Lb cense Law does not apply to an owner ofproperty who Wilds or impoivea lhemon,and. 202 — UNDERFLOOR PLUMBING who contracts for such pmjects with a conuacmr(s) licensed pursuant to me Contractor's License Law. 203 - UNDERFLOOR MECHANICAL [:1 I set exempt under Sec. ,B& P C for mix reason 204 - UNDERFLOOR FRAME Owner Dam 205 - UNDERFLOOR INSULATION WORKER'S COMPENSATION DECLARATION 301 — ROUGH PLUMBING I hereby alrum under Penalty of perjury one of the following cieclara6ona: 302 — TUB & OR SHOWER C]I have and will maintain a Cen ficate of Consent 0 ul6in sure for Worker anion, a provided for by Seniors 3]00 of the Labor Code, for the performunceence of of Me 3 03 - ROUGH MECHANICAL work for which this Perm'v is issued. 304 - ROUGH ELECTRICAL ❑ 1 have and will maintain Workers Compensation Insurance, as rtquirtd by Section 3 0 5 - FRAME 3700 of me Labor Code, for me performance of the work for which this permit is issued. My Worker' mpeowtion Insurance emri.r and Policy num r re �Z 306 - HOLDOWNS once. LI Policy No 307 - INSULATION CERTIFICATE OF EXEMPTION FR WORK�R1 COMPENSATION INSURANCE �j-�- 308 - SHEETROCK (Thu union need not be completed if the permit is forma. handled call. (S 1110) 309 - EXTERIOR LATH I)ea') 310 - INTERIOR LATH certifymat in the performance the work for which this permit isissued, lsmall not ein my employ any person in any manner u a er a become subject o the Workers' Compensetimn 311 - SCRATCH COAT IAws mralumrnia. Date 313 - ROOF NAIL Applicant 501 - FINAL ELECTRICAL ENERGY NOTICE TO APPLICANT. If, after making this Ccnificae Of Exemption, you should become subject to the Workers Compensation provisions of the labor Code, you must forthwith comply with such provisions or this permit shall be deemed mvoked. 502 - FINAL PLUMBING ENERGY CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL" ENERGY I hereby affirm that mere is a consnleinn lending agency for the performance of 504 - FINAL BUILDING ENERGY Me Work for which this permit is homed (Sec. 3097, cin. c.) Lende Under's Namc 505 506 — FINAL ELECTRICAL - GAS TEST Leader's Address I cantly mal I have rad this application and gone mat the above Information Is 507 - FINAL PLUMBING Centel. I agree to comply with all city and county ordinances and mute laws relating Io building construction, hereby and aumome upreunwtives of this city to enter upon the INAL MECHANICAL above-mentioned properly for inspection purposes. (We) agree Io ave, indemnify and keep haemlca the City of Cupertino againstliabilideajudgmenm, costs and expenses which may in any way accrue againnsaid City UOFIN N G in his of the granting of APPLCART UNDERSTANDSLAND W I L COMPLY WITH AL NON POINT Issued by WORKS Date SO ULATIONS. Z Re -roofs Type of Roof pplicanVConuacmr Dem HAZARDOUS MATERIALS DISCLOSURE Will lie applicant or future building occupant store or handle haurdous menial as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code. Section Ves `�,� T.lNo All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building mnupanl use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove emit hazardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection. Dismicl7 ❑Yes Nu 1 have mad the humate amn s rials requirements under Chapter 6.95 of the Califor- nia Hcalth &Safety Codc, Secuons25N15, 255 3 ad255J4.1 undersand Uwifthe building Urs not cunemly have a tenant, Nat iI ism responsirility m notify tM occuPenn of me ' aqui nem' hichmugbemetpoor i mceofaCcAfi. era PercyIgSignature of Applicant Date All roof coverings to be Class "B" or better o n r umorizedagent D,te JOB CONEXANT AR SHEET NO OF ;iy spy,„ CALCULATED BY BOB BERTHIAUME DATE 214/2003 JOB NO 54104 PO NO - TEST SHEET SERVED AREA PARTIAL FIRST FLOOR UNIT (E) BUILDING SUPPLY Remarks 41 .-_r , CITY OF •CUPEkTINO 0 - • CITY OF CUPERTINO b Z/ 2 o v 7 T PERMIT APPLICATION FORM APN # mo/oz?/.a, Date: --/f'-02 Building Address: Owner's Name: //�� C_p�C �NC Phone : Contractor: �A �' License #: 33�i7�s�lo s io�l BUILDING Contact: 4I,STIuS N Phone #: o8-379-5so Applicant/Contractor: Fax #: Con. Tax for BQ Zone -3-79 Buildin rmit Info: Bldg Elect Plumb Mech scription: f-� Residential: r Commercial: 1 , Sq.Ft. Floor Area: Z $/Sq.Ft.: z Architect/Engineer: Valuation: �� y� n7 E!C /+tvM - M,gMV14 Gvv Fe of Construction:Occupancy Group: OF Ftc Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ 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 Ener ' 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 New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 1 of 3 01; OF OCUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BNUMULTI New Multi -family Res PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE PbI2 Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Stonn/Rain Water PLUMBING 13PTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Lkppliance Install MECHANICAL BREM 3USWAY Remodel Busways ELECTRICAL. BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > 10K btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance _ ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL 2 of 3 0 • 11 t, CITY OF CUPEI,TINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity 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 Single & 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 USLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL ,ZPERMITFEE 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 J Op zy a� 0. G UO OV �i.'tt U7 U z APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,CITY OF CUPERTINO INII.Iy1N(: - ELKC'I'WCAL BUILDING DIVISION APPLICATIONIPERMIT PLUM nIrvG-MECHANICAL BUILDING PROJECT IDENTIF'IC'ATION PERMI f NO. S 0751 UILBINGADDRESS: SANITARY NO. APPpLIICATIONSUBMITIAL DArI UB Pt{ONE: C COM' ACI(AML"' LIC NO', R GOn �ph CC�� NIC ❑ CONTROLp ��` ARCHITEC iENGINEER: LIC / AIIIIRCSS: CONTACT: PHONE: T-0 /Yl.,k e j(�o�iio/ 93�f-9795 ❑ Consultant Fees Paid by Applies 1t (Initial)L@ BUILDING PERMIT INFO DG F.Ll PLUMB MUCH 1%//_ LICENSED CONTRACTOR'S DECLARATION I herehy aBiru that 1 am licensed maker pmvisions of Chapter 9 (commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION I'IiRMIT ISSUAN- with Section ]110(1)of Division 3 of the Business and Professions Cnie. and my license is in full force and /' c `� License P av Lic, p a s >: Xo Date Cantmcnm RESIDENTIAL: ❑SFDWL ❑ KITCHEN REMODEL ❑AUDITION El PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION C1 INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT DSWIAIMINGPOOLS APPLIANCES -RESIDENTIAL ARCHITECTS DECLARATION I understand my plans shall be ural as puM1lic records 1 ANLI'S lIPTOY Licensed Pnfesumal 211.1001A OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law tar the following reams,Section 7031.5,Bu.siness and Professions Code: Any ciryor county ❑ BATH REMODEIIREPAIR ❑DEMOLITION BOTHER OVER I000XM SIGNS ELECTRICAL Lie which migrate, a permit m construct, alter, improve, demolish or repair any structure Ri /F A prior to its issuance, also requires the applicant for such permit file a signed statement SPECIALCIRC TSC that m is licensed pursuant m the pmvisions of the Cnmracmrs Licenm Inw (Chapter 9 /commencing with Section 701 Division 3mme[LatmessunJ l4nfcssions Crde7 or TEMP. MINER OR i' .E T R that he is exempt therefrom and the basis for the alleged exemption. Any violation of ❑ NEW D$I51 A�'D�SIOLITION 1'OWT:R DEVICES 16 Section 7031.5 by any applicamforapcnnit subjects the applicant macivil pcnuhy Of /Ilt� USERVICE not more than five hundred dollars (S500), �ji�Ap� I R�JV s4YaFa• SWI MMI NO POLL ELEC1"RIC E] 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 (See. 704,4. Business and Professions Code: The Comment's Licenm Law ares not apply to an Owner of ❑Ol'HER Urthf�l ln41 WETS-SWITCHIS-IIXTURP_S 2 NEW RCSIDENI'IAh I'lEC1'k SQ PI. who builds or improves thereon, end who date Hoch work himself or through his our employees, e provided that such improvements oat nm intended or offered for s own his sale.ILhowever. the building nrimpmvemem is sold within one year nfcnm,letion,the SQ. FT MOOR AREA $ISQ.14. mer -builder will have the human of proving that he did not build or improve for pur- pose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractor m 3 construct the prnjW (Sm. 70,14. Business and Professions CO—) The COntmmors I... /✓Y'l -- - - cause law does not apply to an owner Ofpropeny who builds or improves iherem, and QTY. PLUMBING PERMIT FEE who commets for such projects with a contrccnsgs) licensed pursuant to the Contractors PERMIT ISSUANCEC]I License Law. am exempt under Sec. .1f & 1' C Radii manna ALTER - DRAIN&VIiNT - WATER (HA) Owner hate VALUATION �/Ia WORKERS COMPENSATION DECLARATION BACK PLOW I'NOI'ECf. DI -VICE I hemby idfi m under penalty of perjury One of the followin6 dcdartiuns: O DRAINS -19.0011, ROOp. AREA, COND. ❑ I have and will muWam a ColfiamofGmsem to self -in sure far Wmkcr'e Compery cation, as provided for by Section 371X1 of the Labor Code, for the performance of the STORIES TWE CONSTkUCI'ION work for which this permit is issued W FIXTURES - PER TRAP ❑ I have and will maintain Workers Compensation Insurance, as required by Section J]00 of the lxbarCde, far the perfnrmancc of the work lar which Ibis Acmuit is maimed. GAS-IiA. SYS'I'I?M-IINQ4OUFLIDS OCC.GROUP APN My Compensar t ten Tier and Polic 9% Gm'e1'1QFs I'nl icy Na /�Vr MS -13A, SVSTIiMOVEk 4IBA1 CERTIF CAT 017 EMPTION PROM W RKI?RS' COMPS . ATION INSURANCE %IR6II&ING DIVISION IBES GREASE/INDUST RI, WAS 113 IN'[ ERCEPTOR (This section need not ho completed ifthe permit Isfrano hundrel dollars ISI INTI Or less) CREASE TRAP pLANC 'C SITW17R-SANITARY-til' ORM 1A. Taller. I verify that in the performance orma work for which this permit is issued, l shall not employ any persrsn in any runner so as to become subjcet to the Witkop Cantper. P.NER FP.P. WAI'FR HIIAH?R W/VENT'/EI.i?CI'R ,stk m Lawn of Culif..mr, Date Applicant GRAVING F E NOTICE. TO APPLICANT.If. after making this Certilicutear 17 emptio t. you should become subject to the Workers Con 1'ennmion pmvinionv of the LnMa Cn I" you amt WAI'Ii1t SYS'I'E fl Rl1A'I'INC SOILS PEE forthwith comply with such pmvivions or this permit shall he deemed revoked. WAI'171Z SERVICE - CONSTRUCTION LENDING AGENCY I herehy affirm that there is a construction land,., agency fur the polirmenco of NEW NESIDEN'I'I Al. PLMB. SQ, CC PAID Data --RX,p the work for which this permit is issued (Sem. 3097. Civ, C.) Lenders Name 'TOTAL: Lenders Address A BUILDING FE 1 Codify that I have read this application and state that the chase Information is .. erect. l agree to comply with all city and county ordinances and state laws mating In QTY. MECHANICAL PERMIT F building construction, and hereby a dhoriee rep rectuativus Of this city a) enter neon the SEISMIC MIC tI 1, 'ERMI'I ISSUANCE above-mamdnned property for imspmetlon purposes.�.g (We) agree to save, indemnify and keep harodess the City of Cupertino against ELECTRIC FU fIERORADD'TO MECH. PLUMBI liabilities,judgments, initiator] expenses which may immy way.ecow Npumt said City in consequence of the graatims of this permit. AIR HANDLING ON['[ (TO 11,00 CFM)MHOU D APPLICANT UNDERSTANDS ILL COMPLY WITH ALL NON -POINT 3urr 11 AIR HANDLING UNITIOVER R000CFM) / •� gWmmof ApplicaaV tRaDtor Data HAZARDOU RIALS DISCLOSURE EXHAUST HOOD IW/DUGD FEE Will theappliumt or future bei ingrecupuntsmrc Orhand,e hm.Mous material HEATING UNIT (TO 100,000 BTU) as defined by the Cupertino Municipal Code, Chapter 9.12, and the health and Safety Code, Section 25532(0)? HEATING ON1"I (OVER 100.(X10 BTU) ❑Yes ❑No Receipt 4 VENTILATION FAN (SINGLE RISID) WILT thea licant or future Wildin t use a ui t er devices which pp Wilding q Amen emit hezarJOus air contaminants as defined by the Bay Ama Air Quality Management BOILER- COMP(3HP OR 100.0 BTU) BOLL.IiR -COMP (OVER 100,0 0 BTU) District? ❑Yes Fl No AIRCONDII'IONER cp (have read the hazmdous nam0uls myuitermntx under Chvpter 695 of the Culi- ISSUAN EDATE NEW RESIDENTIAL SUCH. SQ. Pr forma Health & Safety Cade, Stations 25505, 25533 and 23534. I understand that if the building ams not currently have a tenant, That o taste o fy the mcupant ua ce afaCerry orthe eryuiremumx which most he met prior to issuance of a Certificate of (kcupancy. ISSUED BY: Ownenmvuthon,,sula,enl Data l , _- OFFICE /