S 0247 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
kARCHI1ECIrENG1'CNEER:
OF CUPERTINO BUII.IIING-ELECTRICAL PERMIT NO.
LDING DVISION APPLICATION/PERMIT PLUMBNK;
CTIDMECENTIFIC C 0247 BUILIIINf,PROJECT IDENTIFICATION l�
NGAIRE � �� L�/� t SANITARY NO. API•LICA'1'ION SUIIMITI'AL DAT
I '1
AML': �l 'P"'"93. vo CO RA 'OR:C NAM LIC NO:
•V) 6 NIC CONTROL p
LIC NO: ADDRESS: ❑
UM
io o S D ( MOS LAI,A%
CONTACT, PHONE. BUILDING PERMIT INFO
HAS , Nftr I,4 ❑ Cansultant Fees Paid by Applicant(Initial) BL ELECT PLUMB MECH
nv ❑ ❑
LICENSED RAC'T 'S DECLARATIONQTY ELECTRIC PERMIT FEE
I hereby affirm that 1 um licensed under previsions of Chapter 9(commencing JOB ESCRIPTION
with th Section7NM).f Division 34th.BusinessuMProfe.ormsCde.sndmy hrenuis R $EIDGNTIAI.
f-0p
in full force and effect. PERMIT ISSUANCE ❑SFDWL ❑KITCHEN RHMODF.L
a UI'� License Class Lit.# APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RF-PIPEZ
P 6 Darn Cotnracmr
m d ❑MULTI-UNIT [I STRUCTURAL
py ARCHITECTS DECLARATION PANELS
Z O 7J. I understand my plans%hall he used as public records MODIFICATION
r�r/y O UPT02MAMPS [I INTERIOR [I CHIMNEY REPAIR
OZ—W4 Licensed Profe.Wintral 201-10M1AMPS IMPROVEMENT E]SWIMMING POOLS
,•:.•4111 OWNER-BUILDER DECLARATION OVER Hint AMPS V5 [I BATH REMODEIJREPAIR 0DEMOLITION
6 1 hereby affirm that 1 am exempt from the Connector',License Law for the
tiyS O d V following nasal.Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
sR 3 LL I"' which nobim a permit to construct,alte,improve,demolish,or repair any stmnure
0-5 priormitsi.......Ioa requires dw.pplican,brsuch permit m file aligned statement SPECIAL CIRCUIT/MISC.
y Ought,is l lcensed pursuant to the provi.sionsofthe Contmcto/s License Law(Chapters) COMMERCIAL:
LV GC (caarrunungwith Seelan)00(did Divisinn3ofthelhum,sand Proressurescothfin TEMP.METER OR POLO INST. `�
ay�M M 0 that he is exempt therefrom and he basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION �Q)EMOLITION
Wm
Section 7031.5 by anyupplicant I.,.permit subjects theapplicum ma civil pc..Ityof POWER DEVICES ErENANT FDD SERVICE.
ay In marc ohm five hundred dollars(5500). IMPROVEMENT
G ❑I.as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
will do to work,and the structure is not intended clamored for sale(Sec.]014,Business []OTHER
W and Profession.;Code:The Contmcmis Liwme Law does nal apply to on owner of OUTLETS-SWITCHES-FIXTURES
4i 3
Fluttery who builds or improve%thereon and whit does such work himself tar through
his own employees,provided that such improvements are not intended in offered for NEW RESIDENTIAL ELECTR Q FT.
sale.If,however.the building or Improvement is sold within one year of comPletion.the SQ.FT.FLOOR AREA pSISQ.Fr'.
owner-builder will have the burden n(proving that he did not build or improve for pur- ®V
you sale.).
❑ 1,asus owner of the properly,um exclusively contracting with licensed comructnrs m
c mstmn the project($.c.]014,Business and Professions Code)The Commemr's L6 /�
c does m
se law ds not apply an owner of property who builds or improves thereon,anti QTY. PLUMBING PFMWEECary MF/1
who contracts loot such projects with u contmm
er(.)licensed pursuant to the Cnntrncmr'n rl �JF -sl(�D
Liccnu Law. PERMIT ISSUANCE
I ma exempt under Sec. .B&P C farthis reason
- AFTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT DE___
I hereby affirm under Penalty of perjury nue of the following declarations:
❑I haveand will maintain.Certificate of Consent to%elf-insurefnr Worker's Compere DRAINS-FLOOR,ROOF,AREA,COND. STORIES TVPIi CONSTRDCOO
satimn.as provided for by Section 7700 of the Labor Code,for the perfnmmnce of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as impaired by Section
3](00 of the Lidmir Code.for the performance of the work for whichrhis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My k rypensminnJrptBaace Cartier enJ Policy num : GAS-1iA.SYSTEM OVER 4(EA)
WNr1(Zs_Policy No.:
CERTIPICATF OF EMPTION FROM WORKERS' GREASUINDUSTRI.WASTE INTERCHKOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not the completed if the permit is for into hundred dollars f$100) GREASEI'RAP
nr less.) PLANCHECK IEE
I certify that in the performance ofthe work for which this permit is issued.l shall SEWER-SANITARY-S"FORM EA.210 Fr.
not employ any person in uny manner so as w become subject ,,the WorkersCompen-
ENERGY FEF.
Z satiou Laws of California,Date WATER HEATER W/VENT/ELECTR
z0 Applicant r GRADING FEE
y NOTICE TO APPLICANT:If,after making this Cenificale of Exemption,you should WATER SYSTEM,TRP.ATING SOILS FEE
become subject to the Worker's Compensation previsions of the Labor Code,you must
(ll E11hwith comply with such provisions or this Penni,shall be detoured revoked. WATER SERVICE
I CONSTRUCTION LENDING AGENCY NEW RI'SIDIiNI'IAL PCMB. SQ.FT, PAID Darn Receiptp
VThereby affirm that here is a eon%msction lending agency lar the perlonnancc of
Fth/'work fur which chis permh Is issued(See.3n9Z Civ.C.)
U Lenders Name TOTAL:
'y 'TOTAL:Lender's Address /
I� 0. I cedify that I have read this application and sate ohm the above information is BUILDING F[iL'
correct.I agree to comply with all city and county ordinances and state laws relating to Q'rY. MECHANICAL PERMIT FEE /
UZ SEISMIC PEE
building construction,and hereby aathorizn represcamives of this city m enter upon the
Amve-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC PEE
(We)agree to save,indemnify and keep hamde%s the City of Cupcniom against
liabilities,judgmems.costs and expenses which may in any wuy accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANTURSTANDS AND WjtJ.COMPLY WITH ALL NO POINT AIR HANDLING UNIT CTO 10,010 CFM) MECHANICAL FTE
SOURCE .,1 IONS.
/ Z 9 AIR HANDLING UNIT(OVER 10.1010 CFM) CONSI'RUCTIONTAX
n A plic.npCnmmnnr am EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS St IALS DISCLOSURE
Will the applicant or more buil goceupant store or handle hazardous material HEATING UNIT(TO 100,0410 BTU)
its defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda.Section 25532(a)'1 HEATING UNIT(OVER IOn"BTU)
❑Yes ❑No VENTH.AI'[ON PAN(SINGLE RESIDE PAID
Dom Receipt X
Will the applicant a future Building accupanl use equip tom or devices which BOILER-COMP(3HP OR 1110,000 ITru)
mit hazyNous coir oweantinanu as defined by the nay Arca Air Quality Management ZISSUANCt
.
District? BOILER-COMP(OVER 100.0(10 BTU)
❑Yes ❑No
I have and the incautious materials onammmems under Chapter 6.95 of the Cali- AIR CONDITIONER
tondo Health to Safety Coda Sections 25505.25533 and 25534.1 understand that If the NEW RES]DPIAL MECI1. SQ.Fr
building does not cutremly have n tenant,Fed it is an,re,,mmihility m notify the occupant
of the requirements which must he met Prior to issuance of a Cer ificme of Occupancy.
Owner or autbcrized agent Darn TOTAL:Nis
OFFICE
MACS Lab, Inc. Sulk Asbestos Analysis
2070A Welsh Avenue
Santa Clara, CA 95050-2542
Report �
(408) 727-9727 �� p
• ,. . PLM ✓U
o 4 2/1/9
MACS Lab, Inc. G' �Nsp 9j
Field Service Department parson to corna�it bOFC1 oy a�b I
Fp
2070A Walsh Ave. Contact phone: ' (4�<;�4727��hENT
Santa Clara CA 95050 FAX phone: (40e) 727-7056
t
Analyzed on: June 30, 1997 at:14:17
Corresponding Involve number. 5271
Job Numbe 97- 09
•Analyst: Laboratory manager: i"
HN (signature) (signature
-, Job Description: Maru Zen Construction - Paul's Restaurant
Lab Sample Client Sample Number I Asbestos Fibers resent Remarks
Number and Description dsteoted9 p
L52715-1 1 Yes 35%Chrysotlle" Bray homogeneous transits. Balance of
Tranalle panels parapet wall roar side 2%Cellulose sample to cementltbus.
L52716.2 C2 ) Yes 10%Chrysotlle' Black homogeneous caulking rear parapet.
•
Caulking rear parapet wall 20%Cellulose Balance of sarripla Is organic binders and° unspecified non-fibrous material.
11% Fiberglass
L52715.3 3 N.D. 38% Fiberglass Black homogeneous craft paper parapet.
Craft paper parapet wall to roof transition 3% Cellulose Balance of sample Is organo Wallen and
unspecNied non-Ilbroue material.
L52715.4 4 Yes < 1% Chrysotlle` Off-white homogeneous )olnt compound
Wallboard system oollected In 17% Cellulose and plaster.Balance of sample Is
unspecified non-fibrous material.
storeroom 1% Synthetic
L52715.5 r3 ` ) Yes 1%Chrysotlle' Off-white homogeneous tile. Balance of
Off white US flo"ortele storeroom 2% Cellulose sample Is unapedllsd non-fibrous material.
r 1% Synthetic
L52715.0 BJ` Yes 5% Chrysotlle' Black homogeneous mastic. Balance of
Mastic for 9x9 floor the store room 3% Cellulose sample Is organic binders and unspecified
non-fibrous material.
1% Mineral Wool
End of report.
' Chrysatlle, Amoehe, CrooldolRe,Tramolhe, Actlnopte, and Amhophylllte are asbestos fibers. N.D..None Defected
No rope,may rota roduaw s■ In u■red wltn 1n�p■IRllulon pf AMC" Ino.inI■Nppe pets,0 y a T■101 t«0■e.
pas■wm h■au w■rtw.1,m.ntlia TMS 0M so ■r 1P� ru R■a.anw0}°i•1.sn P■n 7Yt rt„ F 'TI,
m•nee. P ra■nutp■.u.•e°ro•1m•e■.YIIOe dab , Isd I■er , try■„.�ol�o .�aPMn�� eyrrtn
�� Q PrbOr■m(NVU,�NO la I■bor■tary numWf 101 We. W 0(a Mm■nt p Or N ti0'^�b1400n '
u■Imy as a n Wt Ol tNe a al It D. Ne.1 ' . °Annul me be
wh■n Abw site is 1q■OIN 10(1,TALI Wly,q°iheuf0 he ui■d O�i en IlmmeO ■u•p�a , ro� au of we a Other m■wtYu
t Page 1
VLYTRN 00005 USAN U6/SU19'/ 11stlsll (11'718'79 NORMAL NUTICE
,6sage Number: Cil"7187b HocGived by U814N at U984 on 06/.0/97 by HQBF HT
Work 1leginss U7/OS/V / at V900U Notice : U37 nrs Priority : i?
Caller's PIAS NHKHJIMH
Company: PIHHUZt&N UUNt)I
Address . 27v6n HUHSthUbt LHNt
Gitys LU6 HLlu6 States CA zip: 440de
Telephone: 415-493—iiVV4 I'ax: 4lb-493-41bb
Alt # (s)
Nature of Work: Ulu 'IU iNbl ILMM LLEC L
Done fort PHULIb HtSIHUHHNI
F'oreaans 148V Area Markey in White Faint
Gere fit Types UNK
Locations
Stryet Address . IL)'%(1V UE HNzA BLVD
Cross Street : bULLINUER ktUAU
WRK LOC NR ELEL: kOLE. F'EH L:ALLER
Places CUPLRI'INU Countys BANTA CLARA iitates UH
Map Books SANTA LLHHW
Page Grid
0059 E05 OUby LOb UUb9 F05 0059 FU6 0066 HUa 0060 H06
Long/Lat Longs —18L2. 036645 Lasto 37. 310500 Long: —128. 025409 Lats 37. 316504
ate Grid is IItAzS, 110 Ns 298, 773 Eo l, b5b, 412 Ns 600, 906
ont tos
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