S 1396 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO
lit)IL111NG-ELECI'RICA L lg I'1'NO
BUILDING DIVISION AIIPLICA'I'ION/PERMIT PLUMBN;-MECHANICAL 1396
BUILDING PROJECT IDEN'fIFICA'I'ION
BU I LDING ADDR FSS: SANITARY NO. APp1.1CAr1UN SUBMITTAL DATE
'flPiNNERS NAME, I'..ONlh lrN'rRAC10R:5 NAMIi: LIC N
NIC C(1NTR(lLp
ARCHI' iCf/F, GINEIiR: LIC NU'. lDRESS: ❑
3 M u �? IdKa
CONTACT': PHONE, 7 BUILDING PERMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) BLDG EEI' PLUMB METH
LICENSED CONTRACIOR'S IICCLARAI]ON QTY ELECTRIC PERMIT FEE
1 hereby.ffml flat 1 am ill,Wed Under pravisinmx or Chapter 9 aoltttncnung JOB DESCRIP'f10N
C
CZ with Sretion 9010)of Division 3 Orme Husine..and l'mresxina.Cpe,le�,nn nyliccnac is RESIDENTIAL:
WOO / LLj�' I'IfRMI'I'ISSUANCE RESIDENTIAL
WUF 1'cevserCl`nal coed. 'LQ LiC,X 671, $ ❑ADWL KITCHEN RE-PHIE
<—U AI'PLTANCIiS-HGSIDIiN'I'IAL ❑ADDITION ❑PLUMBING RE-PII'li
I..:ZIy ¢ Canmeamr
'" URAL
Q A CHI MCrS DECLARATION ❑M11ULT1-UNIT ❑MODIFICATIO
F I undemind my plims,httl to Uwl as public records IANLIS CHIMN YREPA
Z R UI"rU 21XIAh1 V5
❑INTERIOR ❑S CHIMNEY POOL
�yF4 Licensed lsrdeai...I 201-10)(AMPS IMPROVEMENT E)SWIMMING POOLS
Qy$� OWNER-BUILDER DF.CLARA'I'[ON OVER IIX0AMV5 [I BATH RFMODEUREPAIR (]DEMOLITION
x i.
Q 1 hereby affirm that I am exempt Rw ant the Contractor's License lafar the
X 3.U fallowreon
ing ro .(Section 7031.5.Business and Prafc Jon,CIA.:Cc:Any city or carry SIGNS FLUCIRICAL ❑OTHER
W m N which requires a permit to construct,alter,improve,demolish,or repair any ewcturc
ati-A st poor to its itoence.also requires the applicant for such permit file a signed surenwal SPECIAL CIRCUI r/MISC.
del} that he is licensed Pursuant to the provisions of Contractor's hicenx law(Chaprcr4 COMMERCIAL:
WW 0 (commencing with$sniff]p)q of Uivisianinf]he Husineu and l'rofexsians GJO or TIeMP.MI TION
OR Ix)LIiINST.
a d c 5 that he is exempt Iherefmm anal the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
��� Section703 IS by any applicant for permit subjects the applicant to penalty o! IY)WIiR DEVICES TENANT ❑FO :RVIf'
F.ZY nee marc than Gvc hundred dollars($500L IMPROVEMENT
SSp El Lc,owner of me loco .or my employees with Wages as their sole compensation.
SWIMMING Ircx)LIiLECIHIC OTHER 11
L will do the Work.and mcrmctute is not intended or offered for%ale(See.7111,4,Buanms
W 3 m and Pmfessions Code 'Me Commdnh License Law Jucx nm apply m en owner of OUILIi1S-SWITCIIIi,S-ITXI'URfSlyl
pmpenY who builds or improves Iherean,and who dens such work himself or though
hix own employees,provided Lha sueh improvement,.m no,intended ar olie¢d for N1iW RP_SIDENTIAt.ELECI'R SG FC SQ. r.FLOOR AREA 5/SQ.PI'.
role.IL however,the boiling-impmvcmcnl ix sold within one Year of contplaion,the
mer-builder will have the burden of proving That he did fol build or improve for pur-
"t,ofsale.). 'IYl1AL: P
Fj 1,as owner of the pottery,am exclusively contracting with ms licensed coedoto A I h
cnmwm
et the piece,(Sec.7044.Bosess and Profe,ians Ctde:I Ira,Cnmmnor'I a- n- rt V
c Law dc—not apply to an owner of propeny who builds or improves thereon,and Q'IY. PLUMBING PI7RMIT FEE A
wbtcantmaa nonsuch projects with acturacterls)hcenwl pursuanttomc Culfmcloe% .I/�, Q9
License Law. .B& 1'I?RMI'r ISSUANCE: �I 1,7 A1111
El um exempt under Sm. I'C far this reason I
ALTER-DRAIN&VIIN'I'-WAI ER(EA) /- VALUATION
Owner Date t1 IIIY V
.
WORKERS COMPENSATION DECLARATION I{ACK PLOW PR(NFCT.DEVICE
1 lermhy affirm under Innulty of perjury ane ul the following dec'Iamtions
❑I havclodwill maintain u Ci,mflim If iwino,sed-inwrc fur Worker',Cumpero DRAINS-FLOOR,ROOF,AREA.COND. STORIES I YIN:CONST RUC110N
emiun,as pirl for by lesion 371X1 at the IaMu CWc,for the pedinnrmce-'I'he
work fur which This perms is hued. IqX I GRES-PER TRAP
Ej I have and will ammonia Worker's Campcmvution Invurmce,o.v rquinJ by Section
37S)of the LaMu Code,fur the petlnnnanec of the work fin which this pernil is issued. GAS-IIA.SYS'rl',M-1 INCA GO,J., OCC.GROUT' APN
MyWt nap nxutiry�Inter my'cr. ri rad folic nmnher are:
u icer Po1ivy Nn.: GAS-IIA.SYS'I I;M.UVER 4(EA)
CERT,gCA'r1:()It 13XIIMIsIION IzROM WORKERSCREAS191NUUSIRL WASTE INTERCEPTOR
COMPI:N$AI'1DN INSDRANGII BUILDING DIVISION FEES
(l'd,clinnnced not hccumplcicdlffill,pennil is I,, hundml doldho,S liXb GREASE'I RAl'
PhANCHIiCK hlili
n lust
Iccrlil'y'crionic!III, rloarc nfineworoun,aichmloflu, lve 'CJ,Wall I,a- SIiW13R-SANITARY-S'FIRM 8A.21X1 F1'.
not cmpluy any Puaon in any ucnnurron ux lis Ixromesubjda m the Makes'Cwnlam ENERGY PIHt
Z scion Llwa of Cahtords.Dam WADdt HIIAI'EIt W/VEN'i'/I'.I.EC'I'R GRADING FEE
00 npplicnnl
ti NGFICE 10 AI'PLICAN'It 11:Nle, lot s C'edlfiaNu at Hxen.ption,yon should WA'1'HR r13
SYS' M/1'RIiA'IING SOILS FEEhrcoincsnhJcr'I ei the Wnrkud Cotnpcnsuliun prnvininns of 0th I,aMn Ctak,Yuu muxt
Qrofhwith onnply with such I, ciaians a this p snit shall be deemed invoked. WSJ:R SERVICE
CONST R11C1'lGN LENDING AGENCY NI?W RIISIDFN'1'I AL I'hMB, SQ.FI'. I'AIO
U ZI remb ffirnnha mcreap
ia. mn¢tion lcnd'mgr,ro,lindo erfurm no,ol
O Dam R ciptp
W L✓ the work for which mix perm.,is oamd(See.3097,Clv.C)
To
O V Isnder's Name
LcnJur'x AJdrms TOTAL.
r a 1 certify that I huvc read an,applmudon and clue that the.bwe ial'nnnatiun is BUILDING PCF
Lam. to cancer.11111.comply with all city and eoumymdinances and slate laws relating to Q'IY MECHANICAL.PERMIT FEE SEISMIC FE
V Z bottom,consmctian,und hembylool rulcmpmxnntives al this cilY to miser upon the
above-mentioned plopcfy for inspection purposes. PERMIT'ISSUANCE ELEC Fr
(We)agree to save,inJenmily and keep hamde,the Cay rt Cuperom,aloin,,
Iiabilhies.judgments,costs and expenses which may many way accrue ag.insl said CoY ALTER OR ADD'IU MECIL FLU ING FE
in syr d the granting of this pennil.
APPLIC UNDERSTANDS AND WILL COMPLY WHU ALL NON-POINT AIR IIANIl1.INC UNIT(TO 10.000CFM) MECHANIC FEE \
SOURCI
REGI LAI
ilk / � ',�1 '� AIR HANDLING UNIT(OVER 10,000Cl2M) CONSTRU TION TAX
Signamrc Applu,m/Commaar ^I ,or /S EXHAVS'1'HOOD(W/DUCIT HOUSING MI ' TION FELE
HA7.ARDOUS MNTERIAI S DISCLOSURE
Will lble.,teuntor fummbuildingweupnt srneenhandi.hamrdouxntaen.l HEAPING UNIT(to IW.I)(MI BTU)
as defined by the Caper ins Municipal Cale,Chapter 9.12.and the Ileuhh and Snfdy HEATING UNI r(OVER 100,000 BTU)
CWc.Section 255321st:'
p ye, Oslo VENT'[LAI'ION CAN(SINGLE RESID) PAID
Doc Receip
Will the applicant or fare building a<upant use equipment or devices which li(lILI1R-COMP(3HP OR W.(N0 BTU)
mit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Di.ona9 BO ILER-COMP(OVER IM.00)BTU)
0Yc. ❑No
Ihow read the hvauJous flumals nquimmcoa-undo Chapter 6.95 of the Cull- A IR CON DI I'ION ER ISSUANCE DATE
form.Health&Safety Clark.Sections 25505.25533 and 25514.1 undrnnrN shut if the N'WRILSIDHNTIAI, P
building Jtcs nee currently have a tenant,that it is my responsibility to natily the a'svpanl
of the reyuircmcntz which oma he met poor m isuance of a Ccuificac of(kcuryney.
Owner or amhunuJ agent [)am TOTAL: ISSUED BY: —
OFFICE
03/23/1990 13: 59 5103575702 ASSOCIATED MECH. INC PAGE 02
3-20••00: `0:39�M:IrO In3U�DnCD ILLU tlUtlUDLLI{M E t! �
A QRP_ CERTIFICATE OF LIABILITY INSU-1MCrm v DATE"MID"'"
SOC-4 03/20/98
PF-�Dueta THIS CERTIFICATE IS ISSUED AS A MATTER F INFORMATION
Insurance Brokers, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Box 58152 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
5 De La Cru2 Blvd. , Ste 200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Santa Clara CA 95050-8152 COMPANIES AFFORDING COVERAGE
COMPANY
-727-6222 -727-2025 A California Compensation Ins Cc
WSURM COMPANY
B
Associated Mechanical, Inc. COMPANY
Michael or Amina C
631 Montague Avenue COMPANY
San Leandro CA 94577 D
COVERAGES
THIS M TO CERRFY THAT THE POLICIES OF MEURANCE LISTED BELOW HAVE BEER ISSUED TO THE MUM NAMED ABOVE FOR THE POLICY PERI W
MMGTIA NOIWIMBTANDING ANY RSOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT KITH RESPECT TO WHICH THE
CCRTFgATE MAY BE ISSUED OR MAY PERTAIN.THE MEURAWS AFFORDED BY THE POLICES DESCRIBED HEREON IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND COMMONS OF SUCH MMES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAM CLAIMS.
CO TYPEOFMSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION tIM118
LTR MTE(MVIDDIYY) DATE(MMMOrM
GENERAL LUUU1JY GENERAL AGGREGATE I
W M NPMU GENERAL UAWLnV PRODUCTS•COMPIOP AGO S
CLAMS MADE DOCCUR PERSONAL S ADV INJURY E
OWNERS A CONTRACTOWS PROT EACH OCCURRENCE I
P02 DATIAGM(AM w M) F
MED ESP(AM
AUTOMOBILE LIABILITY
AI'11'AUro COMBINED UNCLE LIMB F
ALL ONNEO AGTGB
BDDar IruuN. I
SCHEDULEDAUTOS IP PIITIDII)
HIRRIDAUTM
BOwlr IMMRY I
TIONaWIlEOAUTOS fin AeeICR111
PROPERTYDAMAOE E
GARAGE LIABILITY AUTDONLY-EA ACCIDENT E
ANY AUTO OTNBR THAN AVM ONLY:
EACH ACCIDENT I
AGGREGATE E
EXCESS LUUmJTY EACH OCCURRENCE E
UMBRELLA FORM AGGREGATE S
OTHER THAN UMURELA FORM TU f
WORIERSCOMPDNsATIONANO
EMPLOYOW LIABLTTY ELSACHACCIOENTSS 000 000
A THEPRQMlTORI X MOL G976160166 06/24/97 06/24/98 eLUREABE-POLILY' 51,000,000MIr
PARTHERWMCUME
OFRCERSAR! EXCL EL w6EABE-EA EMPLGI'UE S 1,000,000
oTNDT
oeSCTlfVfgN of oPEAAnONBIppLOOT�UTIONSIVERIC ESB►ECIA7,LfTEMS
All
Paymant o1 Yroma mois Ten (10 Days ��naa k676896 Cancellation for
CERTIFICATE HOLDER CANCELLATION
Cl,imFC SHOULD ANY OF THE ABOVE DESCRUED POLICMS BE CANCELLED BEFORE THE
EXPIRATION DATE TMBREOF.TM ESUMO COMPANY WILL ENDEAVOR TO MAIL
City of Cupertino Building 30 DAYS WRITTEN NOME TO THE CERTIFICATE HOLDER NAMED TO THE LUT.
• Inspection Dept.
10300 Torre Avenue BUT FAILUREro MAIL SUCH MOTICEEHALL IMPOSE!NO OIRJGATION OR Wel1TY
Cupertino CA 95D14 OFANY=0 UPON THE COMPAoIIIY,1,L ITS AGENTS OR REPRESENTATIVES.
ACORD 26s(1196) ®AC0RDZORPORATION.1See