S 4337 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUD DIP*G DIVISION ' APPLICATIONIPF,RMIT PLUMBING-MECHANICAL. S 4337
II EMi G PROJECT IDENTIFICATION r I`'
Ii ILDINGADfi SANITARY NO. APPLICATION SUBMITTAL DATE
a isc�x 7-/3-r/9
NER:S NAME.: PHONE: CONTRACT'OR'S NAME.: LIC NO:
_ NIC CONTROL p
19
ARCHITECLENGINEER: LIC NO: ADDRESS: ..Ikassylafl ❑
CONTACT, PHONE.: ,.j BUILDING PERMIT INFO
❑ Consuitant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ® ❑
I hereby allimr that I licensed a der pro ns of Chapter 9(cm me n OTY. ' ELECTRIC PERMIT ICE JOB DESCRIPTION
LICENSED CONTRACTOR S DICLARA I ION z',
ng
'DOZ with Seainn](R10)ofD nJ dNe Basin: dlY Fissions Cade,andm bee
O O PP.RMIT ISSUANCP.
In Intl farm a sd efteu
st RPSIDENTIAL-
W E; SFUWL ❑KITCHEN REMODIiI.
V License as. Lic.g
y<i Date CHM m Ca APPLIANCES-RGSIDEMIAL ❑ADDITION ❑PLUMBING
URALRE-PIPE
Fly ARCHITECT'S DECL+ TION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O y 7�. I understand my plans shall he mel as public records MODIFICATION
OZ-0 UPTO200AMPS I El INTERIOR ❑CHIMNEY REPAIR
Q�2F,w Licensed Professional 201-I(NNIAMPS IMPROV iHNT (]SWIMMING POOLS
.] OWNER-BUILDER DECLARATION OVER I000AMPS ❑B REMOU-URPEAIR El DEMOLITION
Q I hereby affirm that 1 um exempt broad,Canadian,r'.c License Law for the
xnx�L V following reason.(Section 7031.5,Business and Professions Cade:Any City mrcounty SIGNS ELECTRICAL OTHER
W 3 t y which requires a permit to construct,alter,improve,demolish or repair any structure !.{'!r
�O� prior to its i.vsuanm.alf,conuircv Ne applicant for such peoutm File a signed aummmit SPECIAL.CIRCUIT/MISC,
001,
�y that he is licensed pursuant to the provisions of the Contractor a License Law(Chapter 9
WCQ� (commencing nob Section]0foof Drvisiom Sof the liminessand Professions CW,),,, TEMP.MHfERORPO ,INST. COMMERCIAL,
dpi5,Do C that he iv exempt therefrom and the basis for Ne alleged exemption.Any violation of _ [I NEW BLDG/ADDITION ElDEMOLITION
Www
Section 7031.5 byany applicant for apendadjects t heapbcant ten civil penalty of POWER DEVICE' IR
❑FOODSERVICE
not more than five hundred dollar,($500), n
OK
=QDl,as awncrnftheproperty,nr myemployceswith wagesmtheir.vole compensation, SWIMMIN O0L ELECTRIC
will de the work.and thestanctum is not Intended or offered for a0a(Sec.7B. Business
1 and Prefvoinns Code The Contractor's License Law does not apply at an owner of OUTL-'S-SWI'I CHF.S-IgXTURES
Property who builds tor impmves thereon,and who does such work himself or through
his own employees.Provided that such improvement am not intended or offered far RI'SIDF.NTIAL ELF.CTR SQ Irl'.
ade.lf,haweveq the huiid'ntgaT intpmveumm is sold within....cyan.(exnnplandar,thn .FT.eabuilder will have the burden of proving that he did not build or improve for par-
ynscafaaleJ.1,as owner of the property,am exclusively contracting with licensed contractors doTO'TAL:a mstmenhe project(Sec.7044,Emotes,and Professions Code:)The Camracmr'e li-stakelawdoesnotapplymanownerofptopertywhobuild.c or ltnpmas thereon,and QTY. PLUMBING PERMIT ' FEE
License Lcw, PERMIT ISSUANCE 33rSQ
I am exempt under Sec. ,11&P C lir this reason
ALTER-DRAIN&VENT-WATER(IiA) VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent no self-insure for Workers Campcn- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
action,nv provided for by Seat....3]W of the Labor Cade,fordo perfarmence mom
work for which this passu is issued. FIXTURES-PEIt'I'ItAP
57(1 have and will rommum Workers Compensation Trainmen,as required by Section
J UOof Ne labor Code far the perfasmanceofNe work for which this pemail is issued. GAS-IiA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My WorkiCpGampcH�nc�.ttia ksu� rend policy n
Carrico��CC1l'1 rnncqutnm Policy Ne, c�Gai.5 GAS-EA.SYS'1 ENTOVER 4 LA)
CERTIFICATE:OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(fblsse,ianneed nrnhe completecrm
d flhepitisf..oo b
nnd
naddollass IS 10 .9UILDINGDMBIOMFEES .
ar less) GREASE TRAP PLANCHECK FEE
Imnify the in the performance of the work farwhich this Permit orkes'Czarist SEWER-SANITARY-STORM EA.200 FT.
not employany perso ymr tae usmbeconsuM11 m eWorAers'Comlwn- ENERGY PPA
Z ",I ' .aws of Califo t•acne y` t� -{h
ry J; 9 WATER HEATER W/VENT/ELECTR
Z O Applicant �J1 U GRADING FFE
y NOTICE TO APPLICANT:If,otter making Nis Cenifcate of Esemptien,you should WATER SYSTEMOMEATINO SOILS IRiE
a 5 hecnme nnbjoul nr Ne Worker's Compensation pravlsions of Na Lnbaf Cade,you must
W F.a forthwith comply with such provisions or this permit.shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING banrna AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V I hereby which his
the there ivaed Ser.30V7,
agency for the perfarmuneeof Da RoceiptM
U. HLhe eaderk for which this permit is issued(See.309],Civ.CJ
Lenders Name I TOTAL:
>� {U Lender'.,Addm,, TOTAL: L
1 certify thin I have nail this.,han ion intrinsic thin locative it, Is O, BUILDING FIB
Fh correct.Talmo toromplywhhall cly'anderumy ordlnaacesamdsteehwa achimgto QTY. MECHANICAL PERMIT " PEE
V building construction,and hereby authorize representatives of this city menterupon the SEISM IC FEE
nbtwe-etcationed p otacay for inspection pagta,c.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,cosamal expense,which may in any wayaccme against said City ALTER OR ADDIO MECI I. /I r /O
in consequence of the granting of this poria. PLUMBING FEE `fJt AIS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRIJC7HON TAX
Sigmmrc nl'Appllem HAZARDOUS
Data EXHAUST HOOU(W/IIDC'q HOUSING MITIGATION FEE
HAZARDOUS ldi.,oiA1SDISCLOSURE
WilFdneyteCupertnor o MariciIadCoda. upam stereo.handle Haulthasmatnrial HEATING UNIT(TO 100.fR10 BTU
ns defined by the Cupertino Municipal Code,Chapter 9.12,inti the HataIN and Sufcty
Code,Section 25532(x)? HEAPING IINI'I'(OVER I(ITI BTU) /�
Yes 9No VENTILATION FAN( GLE RESID) PAUL ' �' --
mc Receipt g
Wifl the applicant or future building mseTc nl use equitrmem ar devices which /
emit hamNaus air camaminont as defined by the Nay Area Air Quality Management
BOBLER-COMPKHP OR 100,001 BTU) O S�
District! 'TOTAL: �l
❑Ye.s f6No BOILER- M P(OVER I(M.000 ITU)
1 have read the hazaMsms materials regeimmarts under Chapter 6.95 of the Coli- AIRLiIADITIONER -SU NCE DATE
fnmia Health&Safety Code,Sections 25505,25513 and 25534.1 understand that if the NEW RESIDENTIAL MECI(. SQ.ET.
building docs not Cm andy bava a tenam,that It is nay nasporeihllity m notify the occupant
of the est which must be met Puerto issuance of a Ccnlftcare mf Occur ancy.
aAe14uxfil. 7 7 q�
Own nIs
obtained agent Date TOTAL, ISSUED Y.
OFFICE
. - ... NB'
S , %/"�':Ef,E. P O: BOX 807' SAN- FRANCISCO,CA! 94101'--0807 '
- -COMPENSATIONS
J N•. V U�MA NIC'W - -
.F VAN D .- CERTIFICATE OF WORKERS'.COMPENSATION: INSURANCE,
•-'- ' tra °' , s'`"x a, �"'y" OLICY�NUAABER 1548285. - 98,
ISSUE .DATE.* 04 20-98 y', " ; _ t •� _ ` ` CERTIFICATE EXPIRES 04'.20-00• -
a a ..
M d pp
tC Y a's bd X_' y
C:17Y OF9;CUPERTgI;Npi m%,: JOB ALL CALIFORNIM OPERATIONS'
BLDG..', INSP..Ti. DE'PT;, M1 : ,
I 1,0300,"TORRE AVE ',+.;
CL PERTINO"CA 950,14
'7t' F;Thi's s. t deer{ify that;'wee Gave.!sued aiGand'Workers"Compensation•msurance policy in-a,-form approved by;-the,
Califorma.lnsurince Commissi6ne�.,to the employer named below-far the,policy period indicated
.C.,y.�}^r5r n �r�e✓°.yi°'+% r, ' ::; � 1... . 3 .' � . �t�, . 'Z n. � -:. • '
.v.This policyiis not subject.to cancellation by'the+FUnd+except. upon 10 days: advance written notice to the employer. .
zk s� .3• }. � Fl��,�c ;�iin.• rT��f'4i e! Z ��: �f�> .�~ - . .L ;� '` � .: ��-' .. -
4We,,will also give`you.10 days �advanca notices should this-policy be4 cancelled prior to its normal'expiration.,
-
,.. :ay..
--y�Thisicertificatenof msurance is=nonan insurance poltcyr'and does'not amend; extend:or. altewthe coverage afforded,' '
E;;by;,thespoliclei'liitedl�h6rain. Notwithstanding,i6y�requirement. term;,orcondition,of any'contract' or:other-document:.
with,:respect-tot which, this.certificate of:'irisurance�may:be:issued_or.'may:pertain; the insurance.afforded.by,the,
*policies described"herein is sutitect to "t etterms ex(
luswns andt conditions of such policies -
s �.est z >✓ y .gist `�3�„ - Agj x {.' �` A s. �'.�,
zPRESIDENT ,
EMPL'OYER.'S LIABILITY LIMIT tINCLUDING DEFENSEv COSTS 451 000;000 00 PER,OCCURRENCE'.
r, • . ro, .,q.., .
� Y� t s •rX, n '�K •a.'t � _ ti X�. �� s,�'r � .:S^a�as•,_,'.;..
!
k�h�'"• ham'"'' 1 %'iJ „'r�': >t'� `
'f 1 �;♦.� t t
t ..
` `.. '< r,' �,�t{• it.
ar k ''fp•. �•e a'a Xgl N
. ! EMPLOYER• LEGAL NAMES
x
WATER HEATERS ONLY" INC. - WATER HEATERS ONLY,- INC.
500 kIRPORT BLVD'.. k4W.,,
BURLINGAME Ck 94010. :,y:
Z.
- - 7 PRINTED: 03-18-990- PO4"10
TWIS 60CUMENT HAS A BLUE PATTERNED BACKGROUND SCIF 10266(REV.2 95)
acoRD CERTIFICATE OF LIABILITY INSURANCE,;ID GB DATE(MM DD Y
ATER 1 04/19/99
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Tanner Insurance Brokers HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
70 Willow Road, Suite 250 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
asanton CA 94588 INSURERS AFFORDING COVERAGE
hone: 925-463-9672 Fax:925-463-0192
INSURED INSURER A: State Compensation Ins. Fund
INSURER B'.
Water Heaters Only, Inc. INSURER C:
500 Airport Blvd. Ste 240 INSURER D:
Burlingame CA 9400
INSURER E'
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY h"IFUTIVE POLICY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIM DATE MM/DO LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any ane fire) S
CLAIMS MADE ❑ OCCUR MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE S
GENL AGGREGATE LIMB APPLIES PER: PRODUCTS-COMPIOP AGO $
—11
POLICY PEC: LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) S
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident)10— $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGG S
EXCESS LIABILITY EACH OCCURRENCE $
OCCUR F7 CLAIMS MADE AGGREGATE $
E
DEDUCTIBLE S
RETENTION $ Al IH.
S
WORKERS COMPENSATION AND x TORY LIMITS ER
A EMPLOYERS LIABILITY 151626598 04/20/99 04/20/00 E.L.EACH ACCIDENT $ 1,000,000
E.L.DISEASE-EA EMPLOYEE S 1,000,000
EA,DISEASE-POLICY LIMIT $ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
All California Operations
CERTIFICATE HOLDER N I ADDITIONAL INSURED;INSURER LETTER: CANCELLATION
CUPER-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
City Of Cupertino LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
10300 Torre Ave
Cupertino CA 95014 ANY KIND UPON TH S RER,ITS AGENTS OR REPR 2=
ES,
Jane Ann e
ACORD 25-S(7/97) " ACORD CORPORATION 1988
State of Ca6tomia
CONTRACTORS STATE LICENSE-WARD
-
ACTNE LICENSE.
„®,,..374673 CORP
WATER HEA= ONLY. IITC
com�mC36
F,0005731/2001.
.............. . .