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03060145 �ONTlEZO # / ��,ZL PERMIT #��-' � � � ATE G - ��-D 3 ?ROJECT �,..� �/GL P,eO�,�,ES �" ,r�,, �,, / f ADDRE�� lo ( o � c7� �z� �3c.vv APPLICANT��i� 5�s?�s OVVNER� S�i�� i L/ L(�o f'�/'��s AGENCY � �TU s it IN RN status ]nit IN RE"I'URN status Init .�� Bt,�%��1 OUTSI DE PLNG P.W. ° FIRE � SAN. I)IST. ASSE>_�8R � y� HOOD HEAL.TH - -- - - � APN# _ � °�� RES. (LVNG)_ (GARAGE) COMM.SQ.FT.(NEW) T.I. SQ.FT. RES. REMODEL CONTACT,� ��Pr►Mf S �u�a�. F� PHOIVF,# `�/�� f 3 7� FAx�' yas a8a - �a3o „)CI VALU.ATI0�1 {_Z/o� Oeo _ RECEIPT #_ PLN. ECK ENERG CONS'I'RUCTION TAX --------------(Y) (N) GRADIN _ / SCHO��L FEES ------------------------ (Y) (N) SOILS HOUSING MITIGATION FEES ----(Y) (N) BLDG T HEART OF THE CITY ---------------(Y) (N) S�IS NOTES: ELECT _ PLBG _ _ _ ME , f��i JF,n BY DATE TOTAL FEES 03060145 10101 N DE ANZA BLVD HVAC REPLACEMEN� APPLE �� .� �. �a..:.�, �.; a�.� ��„�, ..� . .� _ �.�,.� _ . �� _�,�� . , � _.�,. € � � + €' �i: � _..`:.m ( " � � o •� �T ��e � •�` .�; � � �' �`��r. s U � o � a� y �, ar � L � t�h i � � io � �' U.h � � � � � � � ,n�' � �''' QY ` +n �+� �.. � .�c a o>' �, � a �,` v ` . s� i E � � � �� a�, � a � � �' � � a � �� ' a. � � � � .�t ( ; t SL 7 �p p; yy' i0. tn . . . �� O p . 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O � � ;j � � � �,�� ['�"7 N O d- '�n E N N � � O M Q - 0) � � 4? � i; = t��i Q O O v�i � _ Ql '- �ti = �� n - O � � " __ 7 '9 d __ U7 h� 4? Ql O -�. -S . `�'�' � `n a= � O 3 � `" '° Q VnT � o �' � - �� y � � , -,_ �, •�, v � � � p � � �o � m `� � � Q Q O a' � � u_ � � � tn d � d d � U tn U1 �,� � m L� `Sr - 1 �% ,[ 'J � � 0 m . ".<,,.,,,:{ � � � C � � � � O U � a� 0 � � � a� � � t� � � ` v M <t � V . .. � O O O O .�� . N N N N U 1 i 1 i - ¢� l!'i r N N - � a o O �n 1 i 1 i 4 p � C O'i V V V ,� - ,� O O O O �--,.. � O w � J M � �.. M � Q1 � , , Q? 'p � � � O O O O � � O O O O � N N N N � � l] T N N � C a] � � V � i i i . Q O O'i ''Y V V � O O O O , , � 0 � U o a p i� � a � � J � � � � � r r N r r r r r � � ' ' " - '� � ,. � � , in p� � o . IV V �. � � � -� Q � � o I Q � U . � � � � a �, � , '" ' � � � � � � � — —— r ..i D O � O C7 �� C}"i O r� � a] Q? p] � ��.€ - O � � Q7 �V iU � � �' - y� � a rn Q O � ~ `p 0? ti ." _ 'O � F- � Q � 0�] �Q1 � � O rc H D �J T � C � .. = O D U U Q? � � U V � �� _ � p ... _ � r� 47 � � y y � �U ; � � '� , � � � v, a a � � t � c c ,i ': - � � a �� a Q c �'o c c � tn tn � U u �u v ua o v -� �` [L eZ � o ca to c, o 0 0 0 __ � cn U p +� €. — ln L[7 L[7 L[7 � r f r f - - �� CITY OF CUPERTINO ° ' ` ` su►�oirvc niv�sioN PERMIT C�1N��dAC�Cl12 ZNI+'QRIVIATTt� ; : .. . ,, . BUILDINI]ADDRE$S: � , AIR SYSTEMS�� INC � ' PERM�rNo03060145 OWN6R'S NAME: 3 H 1 STOCKTON AVE , PERMITLSSUEDATE � PHONE: . SANITARY NO. CONTROL NO. , (408) 280-1666 ARCHITE:CT/ENGINEER: � BUILDING PERMIT INFO HLDG ELECT PLUMB MECH C7 CO 0 0 �O p LICENSED CONTRACTOR'S DECLARATION� � � . � V� 1 hcrcby affirm lhal 1 am limnscd undcr provisions of Chap�cr 9(commcncing - JO}�DBSCC1pt1OI1 �a a with Sccliun 7 )uf DiviSion 3 of Ihc Busincxs and Profcssiuns Codc,and my liccnsc is �y in full fort�c f ct. `/ ;�z LiccnseClv -1a �;�.'�J "75�2�� TENANT IMPROVEMENT +y p Dal� .�- Cuntra or ,.w.� ARCHITECCS DEC 4RATION � I��and my lans s tl bc usc ��ni��s �yU �W F' ro css�ona � ��a O NE BUILDE DECLARATION � ny� �a� 1 hcrcby affirm t at 1 am ezcmpt from ihc Cuniracmr's Liccnsc Law for Ibc p O following rca5on.(Sccuun 7(131.5,Busincss and Profcxsions Codc:Any cily or coun�y !�� which reyuires a permii�o construc�,altcr,improvc,dcmolixh,or repair�any s�mcturc °Z y prior ln iL,issuancc,alsu rcquires thc applicanl for such permit w filc a 5igncd slatcmcnt E_� thai hc is I,iccnscd pursuanl lo thc provisions of�hc Contracwr's Liccnsc(aw(Chap�cr 9 Sq.Ft. Floor Area Valuation �FC- (commcnr.ing wi�h Scction 7000)of DiviSion 3 of Ihc Busincss and Profcssions Codc)or y 5� Ihat he is excmpl ihcfcfrom and Ihc bazis for Ihc allcgcd czcmption.Any violalion of 3 2 6 3 4 0 71 . 0 0 Seclion 7031.5 by any applicant for a pertni�subjccis ihe applicant to a civil pcnalty of APN Number �CCll 3I1C T e not more Ihan fivc hundred dollars(5500). � � � p Y YP - ❑1,as owner of llie propcny,or my cmployces wi�h wages az lhcir solc compensation, � wilidoihrwork,andtheswctureisnotinicndcdorofferedforsalc(Sec.7044,Busincss 10 - FOUNDA��d Inspections and Profc:ssions Codc:The Conuactor's License Law dxs not apply to an owner of � propeny��vhobuiidsorimprovesihcrcon,andwhodoessuchworkhimselforthroughhis 102 — . PIERS ownemployccs,providcdthaisuchimprovemenLsarcno�intcndedorofferedforsale.lf, 1�3 — U�',�',R . � howcver,the building or improvement is sold within one year of completion,the owncr- buildcr will have�he burden of proving iha�he did not build orimprovc for purpou of 10 4 - REBAR � ��`��' 105 - ANCHOR BOLTS ❑1,as owner of ihc propeny,am ezclusivcly conuacting with licenscd convactors to construct the projcct(Sec.7044,Busineu and Rofcssions Code:)'Ihe Convac�or's Li- 1 O G — S EWER sc wA7'�'R ccnsc�w docs not apply w an owner of property who builds or improvcs thereon,and 2 0 2 - UNDERFLOOR PLUMB I NG � who contrac�s for such projec�s wiih a convactor(s)licensed pursuani to thc Convactor's �'°°"��.aW. 2 O 3 - UNDERFLOOR MECHANI CAL � ❑1 am r.zcmpt under Scc. .B&P C for this rcazon 204 - UNDERFLOOR FRAME Owncr_ H2ORKER'S COMPENSATION DECLARADTION 2 0 5 - iTNDERFLOOR INSULAT�I ON � 1 hcreby a(1'irm undcr pcnalty of perjury onc of ihe following declaraiions: . 3 O 1 — ROUGH PLUMB I NG . � . ❑Ihavr.andwillmaintainaCcnificatcofConscmlosclf-insurcforWorkcr'SCompcn- 3O2 — TUB cS[ �R SHOWER � saiion,s;providcd for hy Seciion 3700 of Nc Labor Code,!or the pcdormance o!thc 3 0 3 — ROUGH MECHANI CAL work for which�his permi�is issued. � . � � ❑1 havr:and will maimain Wurker's Compcnsa�ion Insurancc,az reyuired by Scction 3 0 4 — ROUGH ELECTRI CAL � 3700 of�hc labor Code,for thc pcdormance of thc o�k ro�wn��h�,�,a��s��e. � 3 0 5 - F RAME My Worl;cr's Compensauon Insurancc rticr olicy um6cr arc: cam �-� ,� � o��Y No.: - z,�yp 3 3 0 6 = HOLDOWNS i %J CERTIFI ATE OF EXEMPI'ION FRO woRKeRs� 3 0 7 — I NSULAT I ON ��(J COMPENSATION INSURANCE 3 O H SHEETROCK crn��o��e�a�o�n��omP��e��rme,��,»��;bm�o��n��a«aa�u�cs�cx» 309 — EXTERIOR LATH ` „��5:.� ��n�rY�,��n�P��m�,a��or�n�Wo�k ro�Wn��n�n�5��m��5�st��a,�5nan�o� 310 — I NTERI OR LATH � emp�oy any person in any manncr sn as io hccomc subjcct to thc Workcrs'Compcnsation � 3 1 1 — S CRATCH COAT � Aaws of Californ�a.Datc 313 — ROOF NAI L PPlicant NOTICF:TO APPLICANT:If,aftcr making Ihis Ccnifcam of Excmp�ion,you shnulJ 5 01 - F I NAL ELE CTR I CAL ENERGY � bccome subjcct to thc Workcr's Compcnsation provisions of thc lahor Codc,you mus� � �O ro«nw�u,«m��Y W��n s��n��;5��5�<<h�5,��m��5ha��a��m�a rc��k�a. 5 0 2 - F I NAL PLUMB I NG ENERGY z � CONSTRUCTION LENDING AGENCY 5 0 3 - F I NAL ME CHAN I CAL ENERGY � N H� [hcrehy aRrm ihai ihcrc is a conswclion Icnding agcncy lor thc perfurmancc uf 5 0 4 - F INAL BUI LD ING ENERGY p� � ihc wurM:fur which�his permit is issucd(Scc.3097,Civ.CJ ' w Q ��a�rsr,am� 505 - FINAL ELECTRICAL � z Lender's.Address 506 - GAS TEST V Q 1 ccnify lhat 1 have rcad this applicaiion and statc tha�thc abovc infonna�iun is � . S �y � correci.l agrcc io comply with a11 ciry ana county ordinances and state�aws rc�ating to S O 7 — F I NAL PLUMB I NG �U building consuuc�ion,and hcrcby au(hori�e rcprescnta�ivcs uf this ci�y to cnlcr upon lhc F I N MEC CAL � W ahovc-mcn�ioncd properly for inspccuon purpoxs. � � � (Wc)agrcc�o save,indcmnify and kccp harmlcss thc Cily of Cupertino against Q 9 �''I � liabilities,judgmcn�s,cosu and ezpenscs which may in any way accrue agains�said City 5 NG , � �,`� in conseyucncc of�hc gra ing of�his permit. 1C;ANT U E T NDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS Date RCE REG ON . � 'v3 Re-roofs wrc of App i n� ntract Datc . HA ARDOU MATERIALS DISCLOSURE Type of Roof `Vill ihc ppiicant ur(uwrc uilding uccupant storc or handlc haiardous matcrial - as definod by thc Cupenino Municipal.Codc,Chap�cr 9.12,and thc Hcal�h and Safcry coa�,�]�;o�2ss3zca>� _ All roofs shall be inspected prior to any roofing material being installed. Ycs �u w�u�n�a��i��o�m��n��ia��s o��P��u zy��me��o�az��«:wn��n If a roof is installed without first obtaining an inspection,I agree to remove emi�hmardnus air conmminanis az defined by the Bay Arca Air Qualiry Managcmcnt all�new materials for inspection. District'? - �]Ycs u � . � � Ibavcrcad�heha�ard sma�crialsreyvircmrn�sundcrChap�cr6.95ofthcCalifor- - nia Hoalth&SafctyCoM,Scc�ons 255D5,25533 and 25534.1 wdcrs�ind that if�hc building noi curtcntly h c a tcn at i�is my responsihiliry to noul'y ihc cecupam of�hc ircmcnLswhic usibc e�P• ��55��,��orac��;r��oro��an�y. SignatureofApplicant � � Date ' — —p3 All roof coverings to be Class "B"or better wq or authori-r. agcnl Datc i � i ' ��, ... �� Y OF CUPERTINO �� ,��, o � �o � (c S. ��rr�F p]ERMIT APPLICATION FORM 3 � CIUPEf�TINO �r� � Z� 3 � � � � Date: � � [/- �� 7 Building Address: , a�o �,L�-�/�� Lv�� Owrier's Name: P one#: LL ,� �r��s �oFf `�� j'' 1 37/ Con r ctor: � ' ense #: ��/Z„ S �P/� . Contact: / Cupertino Business License#: £� C�0 C.�J 1�� --, Building ermit Info: -- -- � Bld�;� ect lumb� Mech Job :Description: � � � , Residential ❑ � � I _ �'��e{�ci � Sq.F't. Floor Area: � $/Sq.Ft.: Cos1;of Project: Occupancy Gro : • � U � � Typ�� o Construction: -`` ? 1 �� - N Quanti Fee ID Fee Descri tion Fee Grou BAPPLOTHER Other Ap liances MECHANICAL BBLDGFEE Bldg Permit sq. foot BUILDING BBOILERI Boiler<=100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to SOOK Btu MECHANICAL BBOILER3 Boiler> SOOK to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu NIECHANICAL BBOILERS Boiler> 1.75M Btu NIECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. T� 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 y BUILDING BENERGYADD Energy Add Multi BLTILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING �,� 2 Z�� -� � 63 -� � � � s � � • CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # : 3 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 32634071 . 00 DATE ISSLTED. . . . . . . : 06/24/2003 RECEIPT # . . . . . . . . . : 22250 REFERENCE ID # . . . : 03060145 SITE ADDRESS . . . . . : 10101 N DE ANZA BLVD SLTBDIVISION . . . . . . . CITY . . . . . . . . . . .'. . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SANDHILL PROPERTIES ADDRESS . . . . . . . . . CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : JAMES LOWDER CONTRACTOR . . . . . . . : DAVIS, JOHN W LIC # 11223 COMPANY . . . . . . . . . . : AIR SYSTEMS INC ADDRESS . . . . . . . . . . : 381 STOCKTON AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95123 TELEPHONE . . . . . . . . : (408) 280-1666 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL - --------- ----- - - ------ ---------- ---------- ---------- -- ----- --- ---------- BPLANCHK PERMIT FEE 1, 092 . 00 928 . 20 928 . 20 0 . 00 0 . 00 BREMA.COVER NO UNITS 3 . 00 43 . 29 43 . 29 0 . 00 0 . 00 BREMPOLE NO. FIXTURES 3 . 00 3 . 33 3 . 33 0 . 00 0 . 00 BREMRECEPT NO. OLTTLETS 3 . 00 3 . 33 3 . 33 0 . 00 0 . 00 BPERMFEE VALUATION 176, 000 . 00 1092 . 00 1092 . 00 0 . 00 0 . 00 BREMREPALT NO UNITS 3 . 00 36 . 63 36 . 63 0 . 00 0 . 00 PPERMITFEE FLAT RATE 1 . 00 35 . 52 35 . 52 0 . 00 0 . 00 BSEISMICOM VALUATION 176, 000 . 00 36 . 96 36 . 96 0 . 00 0 . 00 BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00 EPERMITFEE FLAT RATE 1 . 00 35 . 52 35 . 52 0 . 00 0 . 00 MPERMITFEE FLAT RATE 1 . 00 35 . 52 35 . 52 0 . 00 0 . 00 - - -------- --------- - ------ ---- -------- -- TOTAL PERMIT : 2350 . 30 2250 . 30 100 . 00 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER - - --------------- ------------ ------------------ OTHER 100 . 00 VISA TOTAL RECEIPT : 100 . 00 .u.. _�� _.CL U_ air �(U t]L S (a O r O f0. y _0, O O O m U s LL. d' ��L 2 U U i O * t i"�. ! _ p �' 0311 h ! a r ^"- v -0 LO} Ap � t .j mLLI O a m o o f07 Oi U F T i w p `�o f x o , f ' OL rF s -W � O p � .a'. E o jI IPR--, orte _ - a - 5 f 14f Q) . (U v I y a `�; � v Kx O ¢ v I ! i( ®1 j E 4 s t ` I zg mLD t 0S'O 3!# t UU– t` E r '� � � O .O -O t � ' I I• ' �a 1 e U i CD LOL, OL OL u`y 3 .O i I o o iLO 6 n ! r E PO. f U I ,. I O 00 i �t LLJ OL OL CE LLI fu LLJ "-_ LD CD, CD LL j 'r o o#}{ {r{ rn C 4 � LO O 'OO lfOt 'C J ~.4 2 I • 1 �U! r0� 3iI -' o {i NN fv�t, ;+ o t� U i Imo+ O` '7� n — d 1 4 w1 - M �i t-•n ''�7 �`'" t i � 07101 �i ILS- t Cq J O f "� o "a'i, Q. U I I U�i...__.i1o ''.�3..a_1L..... C_ L j mmQ< 4 Et r (U �� i 1 F, w rr � �3 in ? m a ya E o r %as %� ? % 7 7 «,y aY (U 4Y i O - U cn i L = y y U. _ _ E E o n U CJ E c I i! ' ? y a� y � ar v a C03 cn a� x o . Y, OL �. w �� f0 m O a ay" `m 8 ar d d Q LO U d O 0- I a v ."(a• U IM CITY OF CUPERTINO BUILDING DIVISION CCINTZ2ACTC3R INS URMATIt PERMIT BUILDING ADDRESS: AIR SYSTEMS INC PERMIT NG03060145 OWNER'S NAME: 381 STOCKTON AVE PERMIT ISSUE DATE PHONE: (408) 280-1666 SANITARY 9 CONTROL NO. ARCHITECT'/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 4100 LICENSED CONTRACTOR'S DECLARATION U P 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing - Job Description Ua with Section 7 )of Division 3 of the Business and Professions Code,and my license is N in fullfortc�f TENANT IMPROVEMENT j�? I,iccnsc Ci '1 Lic. +y a Dalr�v — Contra or Lu ARCHITECTS DERATION I o�oand my lans s II he use panite records )WU eL 0 h m esstona n rn O NE BDEUILDECLARATION <� 1 hereby affirm t at I am exempt from the Contractor's License Law for the a O following reason.(Section 7031.5,Business and Professions Code:Any city or county $E which requires a permit to construct,alter,improve,demolish,or repair any structure u Z w prior in its issuance,also requires the applicant for such permit to file a signed statement E_It that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft. Floor Area Valuation Y.FCC- (commencing with Section 7050)of Division 3 of the Business and Professions Code)or y 5 that he is exempt therefrom and the basis for the alleged exemption.Any violation of 32634071 . 00 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy not more than five hundred dollars($500). - P Y Type ❑1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure isnot intended oroffered for sale(Sec.7044,Business 10 1 - FO UNDAd Inspections and Profcssions Code:The Contractor's License Law does not apply to an owner of propenywho builds or improves thereon,and who does such work himselfor through his 102 - . PIERS own employees,provided that such improvements are not intended or offered for sale.If, 103 — UFER however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of 104 - REBAR sale.). 105 - ANCHOR BOLTS C]1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- 106 — SEWER & WATER cense Law docs not apply to an owner of property who builds or improves thereon,and 202 - UNDERFLOOR PLUMBING who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License 1•aw. 203 - UNDERFLOOR MECHANICAL ❑1 am exempt under Sec. B&P C for this reason 204 - UNDERFLOOR FRAME Owner_ WORKER'S COMPENSATION DECLARADate 205 - UNDERFLOOR INSULATION I hereby affirm under penalty of perjury one of the following declarations: 301 — ROUGH PLUMBING ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- 302 — TUB & OR SHOWER sation,as provided for by Section 3700 of the Labor Code,for the performance of the 303 — =ROUGH MECHANICAL work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 304 - ROUGH ELECTRICAL 3700 mf the Labor Code,for the performance of the ork for which this permit is issued. 3 05 - FRAME My Worker's Compensation Insurance rtier olicy umber arc: �— 306 — HOEDOWNS Came-441k C N1 olicy No.: `�,C/A CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION COMPENSATION INSURANCE 308 — SHEETROCK (This section need not be completed if the permit is forone hundred dollars($100) 309 — EXTERIOR LATH or less.) I certify that in the performance of the work for which this permit is issued.I shall not 310 — INTERIOR LATH employany person in any manner so as to hecome subject to the Workers'Compensation 311 — SCRATCH COAT Laws of California.Date Applicant 313 - ROOF NAIL . NOTICE:TO APPLICANT:If,after making this Certificam of Exemption,you should 501 - F I NAL ELECTRICAL ENERGY become subject to the Worker's Compensation provisions of the labor Code,you must zo forthwith comply with such provisions or this permit shall be deemed revoked. 502 - F I NAL PLUMBING ENERGY CONSTRUCTION LENDING AGENCY 503 - FINAL ME CHAN I CAL ENERGY F. I herehy affirm that there is a construction lending agency for the performance of 504 - FINAL BUILDING ENERGY (Yi > the worts:for which this permit is issued(Sec.3097,Civ.C.) w Q Lenders Name 505 — FINAL ELECTRICAL az Lender's.Address 506 - GAS TEST U o 1 certify that 1 have read this application and state that the above information is s 507 - F I NAL PLUMBING cored.1 agree to comply with all city and county ordinances and state laws relating to p v building construction,and hereby authorize representatives of this city to enter upon the FIN MEC CAL U ahove-mentioned properly for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against 09 FI 1—t� liabilities,judgments,costs and expenses which may in any way accrue againstsaid City 5 NG -� V z in conseyucncc of the gra ing of this permit. V 1C;ANT U E T NDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS Date RCE REG ON . 'v3 Re-roofs tore of Appt nt/ ntract Date HA ARDOU MATERIALS DISCLOSURE Type Of Roof Nall he pplicant or future wilding occupant store orhandle hazardous material as defined by the Cupertino Munieipal.Codc,Chapter 9.12,and the Health and Safety Code,[cction 25s32(a>7 _ All roofs shall be inspected prior to any roofing material being installed. ] Yes �u Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all-new materials for inspection. District'? ❑Yes o Ihavereadthehazard smaterialsrequirement%under Chapter 6.95ofthe Califor- nia Health&Safety Code,Sec ons 25505,25533 and 25534.1 understand that if the building JIQU not currently hue a ten at it is my responsihility to notify the occupant of the ircmcnts whit ust be etp• rtn issuance of a Certificate of Occupancy. Signature Of Applicant Date wa orauthoriz. agent D,t(J� All roof coverings to be Class "B"or better I i C Y OF CUPERTINO CITY OF PERMIT APPLICATION FORM 3 CIUPEkTINO API` Z 3 7 ,/ Date: Building Address: / Owner's Name: one P #: 4 00 37/ Con r ctor: L'' ense #: Contact: // Cupertino Business License#: Building"Permit Info: Bldg rec� r1umb Mech )C Job :Description: Residential ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Gro Udo Type of Construction: ............ ` ? 1 Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permit sq. foot BUILDING BBOILERI Boiler<='I 00,000 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> 1.75M Btu 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 Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee ^ BUILDING 63D #4- -C,