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20655 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POIMT PEfd OfVLY nwmi� r.o��nme��in�.�ie� PF.iN9TN0. u�uamR naa�� . �� 2 0 6 5 5 F � � � one: A A � Wner CITYOPCUPERTIN0.BUILDINGDIVI ON _� �co�� ,a�: u�.n�o: APPLICATION I PERMIT — BUILDINGF].EC7AICALPLUMBINGMLCHAMCAL CA RY COMROL p Arc ten gineer. LIc.Na Qrt' ELECTRICPERMIT FEE BUILDINGPERMITINPO naam�: PQ2MITISSUANCE �j{ ❑ ❑ ❑ LICF.NSGD CONTRACfOR'S DECLARAiION L�U IherebyeHlrmtlutlamlicrnsedunderpmvismmo(Chapter9(rommenc- MPLIANCESRF_SIDEMTAL J09DESCM'flON Ingwith5ectlon 9000)0(DlWsion3o(1heBuslneuandPmfeuloneCodq and my lirenu i�In(ull force and d(ect. I'ANOS LlmnuCh� LICM �` L S Da�e CoMnnor , ARCHITECTSDECLARATION 201�1000AAfI'S 1 p,�+�0 ZOC I undentand my pheu sAall be u d as pubtic recorda OVFR 1000 AM['S SQ.Ff.F7.00R ARG S/SQ.FI'. E�t, Lirensed PMessloml SIGNSELECIRICAL �¢p� ONNER-6UILDER DECLARATION � \ Z�.,r� Iherebyaffirmthatlamezempt('vmtheContnaorbLkxnsei�w(orthe SPECal CU17/MLSC p"'S (ollowin awn.6ecUon7Qf15,BusineseandPm(es�IonsCode:M d or t�r�'- 1'. FZ�e'� muntywhlchreyulmapertNtromrtskuR,aller,lmprove.demolbh.orrepalr �M�'.ME7ER RI'OLEINSf. { l, ���G�.� anyatNtturepriorlolbtuuance,aLwrequheatAeappllcaneforeuchperMtto ��Ap�� �/" K�S flle a signed shtement Ihat M1e b Ilreneed pumuant m Ne pmvblov of the - . n ! ���.,C Comnccors Llceme Uw(CFapter 9(commencing wlth 5e�S1on 7000)of Dlvl- gy.�p�j,wNG A�OL ELFCTRIC ' H�O� slon3oftheBuslneasendProfevlovCodNorlhatheieexemptthercfromand VAWA710N �he basb for the alleged exemp[lon. Any vlolatlon o(SeR1on 7Q11.5 by any � ��� '� � � ,J ��� ��w�A �`�65 aPPllo orapermiteubjectetheappllcantloativllpemltydnamorcthan '�'E�ml�FgsFl%711R I � �iai c.��� flve dred dollan(t500). � �n t �� �� H � �.- I.uowneroftM 'o rtry P Y 6 �WR6I�1FNfIALEL 7R�� , .� �W� 7�n p perly,or em lo en with wa n aa tM1elr wle 'FT' T'PECONSIRUCT70\ � mmpensaHon,w111dothework�dtheahuclurebnoHnleMedoro(lemdfor \/ Y' �1 �O sale 6ec.]OE4,Buslness and Pmtessio�u Cade:The Conkanofe Llcevc Izw � �,j5.3 doesnaapplyroanownero(prope�tywhoWlldsarimpmveathereoryand f� p�C.GROUP RES.UNRS wFo dcesauch work hlmsel(orthrough Fia own employees,providM that wch Improve ntaarenotlntendedoro(fcredlorwle.I(howeveqthebuildingor TOTAL: Impro mentlaeoldwltFlno�yeamtcompletloq�heowner-bullderwlllha.e t rdeno(pmving�hathedid�oce�ndorimp���torpu.p�ormk.). Q�, pLUMBINGPERMIT FHE Flp�p�VN� q�N [as owner o(Ihe Property,am eyclualvely wntncHng wlth Ilceved PFRMR ISSUANCE rontncton ro mmtruct the Pmject(Sec.9ply gusiness and I'ro(mlov Code: 7Te Cantnaorl Llmnse!aw don na apply ro an owner d property who pL7IILDRAIN k VFM-WATFR(ErV Wlldz or Improvn tFrnron,and who mnM1acb (m svch p�ojeb wilh a ,tV(actor(e)IimnxdpunuantmlheConcna[m'�LlmnseGw. gp�}7p�y�07ECT.DEV[CE FEESUMMARY , ��JI am o t under Sec. B k P C f�or thb mawn . . O.vner Dae 7//,�/�j/ DRAINSFLOORROpF.AR[iA,COND. SAM7ARY RECpI'I'M 1 O SATION DECLAF,I�1N� �� �� ❑1 Aercby aRlrm that I have a mklfl�te o(consent ro u141na�rt,m a �'��FS����' �i�L'IA% Y N mni(imte of WorMen CompewHon Imurana ora artJicd mpy�hereo(6ec. �LID'f N 3BOO.I�bCJ CASFA.SYSI'EM.IINC.<OUiLEfS PAWCIFE Y N Poliry p RECpP]'M Cnm any GASFA.SYS!'Q.(-OVER6(FA) 9UILDWGDIVISIONFF.[S �Cenlficdcopylsherebyfvml.+hed. GRFASE/INDQSfItLWASfEIMfQtCFP'(OR �LANCH�CKrEE �Cetlified ropy b flled wlth 1he city Iropectlon divislon. 1 CGRTIFlCA'fEOFIXkT1Pf10NFROMWORKERS' CREASETRAI' PA�D I`•`� COMPENSATIONINSURANCE 5�,�_y�M.�.�y�����, Date RCOCI t# Rhlsse<ian need not be completM I(1hc permic is(orore hunEred dollan (stm)o.�es..> ' wn'�'mtfFni�twiveM'/et.Ec'at C•NLRGYFEE Y N Inki(y�hatlnthepcefomunttofthework(orwLlchWspe�mitlnVsued, — — 1 shall not employ any person In any manner eo u co become eubject to cAe WA7.Q2 SI,SIFM/.IREA.P�NG WorkcreCompenvtlonLeweofGll(omis. Wte PAID � Z Appllcant Z p NOTICETOM['LICANi:If,akerrtakingthbCeklfkateofExemptlon,you �WAE9DEMiALPLM6._SQ,67, Dat2 Rett'1 [# � shouldbemmeeubjectmtheWorken'CompemaHonprovblomoftheLabor TOTAL: WN CoAe,you�st(anAwithmmplywlthauchpmvLslovorthtapertNtsh�llbe ' > acemeere�okea. 6UILDWGFGE a p CONSTRUCf10N LEI�DINC ACENCY SEISMIC I'EE , I hercby a(lirm that there is a mwtmnlon lending agency far the peAorm ELLCfRIC FEE � O anreottheworkforwhlcFthisperMtbissued(Sec.3097,CIv.C.) 70TAL: V _ i`°a",N'"" PI,UMI3MGFEE LL � 1<�d�rsnddmse QTY, MECHANICALPERMIT �E MECHAMCALPEE O W Irertlfylhatlhnvcrcadthuappliatlonandstatethattheabwein(ormaclon a Ismnen.]agreemcomplywltAalltltyandcountyordinanmandstatelawn �'FliMffISSUANCE PEESPA[D } y relatingmbuildingm�utrualon.andMmbyauthor'verepmentativno(tAk �— Z diywenterupontheabovcmemlonedpmpertyfmWpecllonpueposn. AL7FRORADD'NMECH. � — (We)agec to save,Indemtify an d kcep harMe»Ihe City o1 Cupertino Datc Receipt# .�,alretllabilltin,Ndmgmenta,coazsande� enuswylchmaylnanywaya�pue AIRHANDLINCL1Mi(fO10,000CFM) SUBTOTAL• egai yln �neeyu�ye�fcM ' thlepermit. �@�'— �� � �/�� AIRHANDLINGUMf(OVpitp,OpOCIM) COIJSTRUCTIONTAX V- V/ si t o(Appllcant/Contractor ee D(HAUS'C}IOOD(W/DUC'q CONSTRUCTION TAX PAID: ' MAZARDOUSMATfN1AL5Di5CL05 NE Willcheappllantorfuturebuildingoccvpantsmreorhnndichairdous IiFATINGU�'["f(N100,OOOg7lp D3te matcrinlasdefinMbytheCupertlnoMunidpalCode,Chapter9.12,and�he RCCCi f�l I Iralih and Salety Code Section 25532(a)i FIFh77NG IIt�7T(OVFR 100,000 gi'U) ❑vn �f Ho TOTAL: �a- Wlllthexppllcantorfuturebuildingoccupantuseequlpmentordevices �FNI7LA'I70NPAN6WCLERFSID) ISSUANCEDATE which eMt beardom alr mncaMnams a�de(Ined by the 6ay Arca Alr �� Quality Maragemcnt Disiricti BOILE2-COMP(3HP Oft t00,OC9 Bi[D 4Yes nNo havereadthehuar�iOusmaterinbrequlre�rcnbunderChapier6.95of 90ILER-CONP(OVDitW,000BN) ��0� �heGlilornia}iealth&Sa(etyCode.SMloiu25505,75573and755b. I .�3 f 111, ��,� . understandlhatifthebuildingdoeenotmrnntlyhaveatenant,thatltLsmy h'EWRESIDEMIALMECH. ' �.F7 �,V V �� evpo J' mnotifytheoav ntoft requlrcmentswM1i me[ p' to uncco! fi re f anry. ��Or��__y� / � L y;nSuuy cro.auino ua- e�t . — nc 70TAL: ���DPY: � OuV OFFICE COPY , \ , � ��_�..--�---�"�"��•~ _.m-r.. �^�-'„�✓- ' �� � � /t , 3 `f'� %t� �Z � . �� � . � � � � 6 ' � ----------. 45 ' -------� ---___.___ ��; _.__. � � � .I � XISTON � R � SIDFNCE M f ` -�� �, 4 . :: • � I ,`'� . ---� � '� p NS CHECKED ¢Y '� � � � � �,X � , �D � • , OATE ,eui�ou+d ... � 3 • ' � � DA�E ELLc,rs,-..�+- ! E , # ; � � ` t ____--- r�— �_j____ . OA7E � ,, ! � , , vwr.,e,r;�._ . ! - n�iE �PLOT . N � � � P � CHECKED BY /� � f ¢� (�' � - ' DAT� 7—6— '`� V Ff G � G. � � � � r ' P � �' } O � . � � �LANPIING DEPT. �� DATB � � �' � � � . i ROVED � �IN ACCOR A CE WITH THE CITY OF BLDG DEPT. � UPERiIN C DES AND ORDINANCES �� u1e 3 —fi� � � ; + ,, / L, t SI NED Vt CL vY � � �S fY � lslJ � �Q � a s �' �' f; T�is set of ¢a s end �peafications MUS R 0 O � � Q ./V ,� `T' � ' b� kept on ihe job at atl times and it is um � � rs.d e."1'" �� N;� I wful to m ke any ci:?nges or alterations � o same w hc L.u.i�il,p_, ermissinn from t e burdm Ciy ertino. �� ❑ � e stamp;ng f his p;zn.�nd specifications ,� r4 ��5��,�n�r � ' � ' t � HALL NOT b ha:d to pe,mR or to be aR !J � �t.,, 11 �II pproval of th violation of any provisions ; U ! �m City 0: inance or State Law, ,Ju�_ ,:� �-1�7 2 3 � ��,. �'f �j�,...�L� BLDG. 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