29831 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFICUPERTINO BUILDING-ELECTRICAL PERMIT NO. /�
BUIItVI G DIVISION APPLICATION/PERMIT PLUMBING-MECHASICA31
I, 2 Q 8
BUILDING PROJECT IDENTIFICATION L J V 1
Sf11LDWGADDRFSS: ./1 /I/I t 1 SANITARY NO. APPLICATION SUBMDTAL DATE
V 61Iv X V
OW ' NAME PHONE: CONTRACTOR'S NAME: I C �
NIC CONT ROL#
A fIECT/ENGINEER:' N DR5: ❑
L
CONTACT: PHONE BUILDING PERMIT INFO
LY !4l' D y O^ ❑ Coluultant I'm Paid by Applicant(Initial) PLUMB MECH
LICENSED CONTRACTOR'S DECIARATIONGf+ I/ QTY ELECTRIC PERMIT FEE
I hemby amml iMi l ani Twm.�d alder pmvi.imn..of Omptcr v(conm,e«mg JOB DESCRIPTION
aZ whh SCctim]IgD o[ ToftheBmimssed PrnfsI too Case, rax vIHUSD'ISSUANCE RESIDENTIAL
1- in full form mid cff v s/ ❑SFVWI. [I KITCHEN REMODEL
l-Zw licrnu Class DcX APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
W D Cmtran«
FO ARCHIECFS DECLA fld PANTOS ❑MULTI-UNIT ❑STRUCNRAL
ZO,� It^'da•I^Itl mY Plw ilull be uW ax public reermis MODIFICATION "
OZ-p UPTO2WAMPS ❑INTERIOR ❑CHIMNEY REPAIR
[-�4F'ul LiecnW Pmfcssioliel 201-100I)AMPS IMPROVEMENT
Mai! fia,I
OWNER-BUILDER DECLARATION
he ConTION OVER 1000AMPS t O BATH REMODEVREPAIR El DEMOLITION
CC 1 hcmby lsoer tlwl 1 I cxempl form the CumructCo,Littna Law for the
y7 V F fihich g sewn.aScan��703 IS,Bosun end Pmfaxima OtOr Any city orcmmy SIGNS ELECTRICAL []OTHER
which ryuiss a pemul m aim%Wl,ehm,improve,nkmulixh,or npaiv ay unewre
Prim In its issuance,also requim the applicant fnr.w[h annit In file a signed eetement SPECIAL CIRCUIT/Misc
y�a2 that h is licensed .Or to the provisiansofac Contratc,.Licence Liw(Chi sel
1+100 (camnrnKingwilh Secfim7t%0)of Divisim3af Budnsuad Pwfmsansode
C )a COMMERCIAL
Tl'MP METER OR POI.F,INST. - '�k
Ow mp he is cxetherefrom ad the basic for the allegd esemption.Any vidvimi of ❑NEW BLDG/ADDMON ❑DEMOLMON
K'�LL Section'/0313 by any applicamfor a pemut wbjeev,do aMIXIML 10•tied Penalty of POWER DEVICES
❑IMPROV [I FOOD SERVICE
rot mac duan fixe nudsJ dullms 155001. OTHERIMPROVEMENT
E=G ❑ I.asownv,rW pe unset«myempbyceawiNwvl:l For Wait thee.
cumpetu mess SWIMAIWG POOL FO,ECfRIC
will dothe wart,Coc vO CorrearxxsLiccnsus,ow dofa aele(Sec.I(W,B eerof [I OTHER
end Pry non,Calc:The CmlmClork Lkcdtt law does w apply to w owner of OVTLEI'S-SWITCIII?S_pIKRIR
3 r his own
who builds«impmvcs 0cmm,eral ale dax such work hint or«eMegM1
his own employees,provider that such impmveoldw on txx imemkd re offend for NEW RESIDFNTIAIJiLF.CIIi �'SQ FT.
Owner howcvcr.Nc build buider prowiti 41
i.wd wiidn Waldorf r,roo,tion,Nc SQ.lei'.TLOOR AREA S/SQ.FT.
Owner hildu will hove lh huNrn of pmviog Nu he did no huilduimlaove fu Far. -
pme of sole.).
❑I.as whar of the Di
1`0y,am esn ss and Poubmi ins with licenser mnmacars m -TOTAL
continuer the
eshat lss.101 T,wnerof. oM Py who nCock)Th Conaereon- est
cerce Lev doesovnepplymun ith.con.tarrywho bed's impm.:x thereon-rest QTY. PLUMBING PERMIT FEE
whocmuvcu f«such projccu with. PUnruvllt to the Conlracmr'. _
Licenm Law. PERMIT ISSUANCE
l ann exempt under So, - BAr P C for Iiia mavm
Owner Dae ALTER-DRAIN'A VENT-WATER IEA) - VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRODIC'L DEVICE CCT not
I hereby affirm under Penny of PvjuD one of the following declarations: , 7 Lit/
��Ihave and wiB wisoio•Cenif sof Consem to self-istwsfm N'mtcr's Canopcm DRAINS-FLOOR.ROOK AREA.COND, 510RIFS TYPE CONSTRUCTION
slakes,as provided fee by Slee ion 3700 of the Libor Cods.f«the perfmrvrce of Its,
work for which this pvmil i,ibsu.d. FIXTURES-PER TRAP
❑I have and will maintain Worker'.Cunpensanon Insurance,an rquiret by Section
3700of Labor Calc,fur the pc+fnrmmmc of 0e wort fm which dins pcmlitu issuer. GAS-EA.SYSTEM.I INC.4 OUTLETS
M' «kers CwnPen.wtlm inwratec carrier oat PMicy numM art:. OCG GROUP APN
u. Policy No.: OAS-EA.SYSTEM-OVER a(EA)
CERTIFICATE OF EXEMI'T'ION FROM WORKERS'
COMPENSATION INSURANCE GRGSMNDU.STRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
.(This section need tla hcsmrdcld if the Pemul is fume humtrd dolen($In)) GREASETRAP
or Ics..) PIANCHV:CK p..
1 ttrufy Thu in IIIC perfortwKc ofthe acne fa whkh thh pemul Is iavxtl.l shall
not employ any Pansch in any mamer,so n to becaaa whjeet to site Wmkm'Cher en- SEWER-SANITARY-STORM E.A.300 FT. ENERGY FEE
ZZ utiao laws,of California,hate WATER HEATER WNENTIELECTR
Applicant GRADING FEE
N NOTICE TO APPLICANT;IL after making Nis Cer ifica,of Exemption,you should WATER SYSTEM/IRENG1,5 SOUS ITS
bccoine subject to the Workers Con Wirturino provision.of the Inbn Code,you moan
aforthwith comply withsuch pnrvlsio I,onhis Pemlit shell be deemed meokd. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.EL PAID
7 Z Il esbYoRirm lhvnot is Irish,30 7.Co,eB•aeY for bac perfmrwce of Uatc RaciprX
UO_ �ace,N nanwia penmilis lxwedareae.3tm.cv.c.)
U Lender's N. TOTAL
U Icdcr'r Addrt.ss TOTAL:
I ecrufy than I lave teal this it'licvion aM sone that the above irJenrulion i. BUDDING HER i
h cartel l agree to comply with all city and county ordnance,and vara laws slating to QTY. MECHANICAL PERMIT FEE
U..� building construction,and hereby vuJwriu spcsmm
entutives of this city to eeropthe SEISMIC PTF.
(We
oMwe- ) dpmpe0y fur' IreGu Mchnz
(Wc)agree ,Ia4mnify eM k rmlcsv the City of Cuaninxt against PERMITISSUANCC ELECTRIC ItiiE
liebilitin ' ' rets ed expenses. may in any way u<rue ageimn.uid City ALTER OR ADD TO MECH.
rcc of
film lin
of this it. PLUMBING FEE
m
dN
\NDS WILL COMPLY WITH ALL NON-POINT AIRHANDLINGUNRfT010.000CFM) MECHANICAL.FEE
AIR HANDLING UNIT(OVER IO,000CFM) ^ 6'CONSIRUCfIONTA%
p innt/Chermacua Dec EXHAUST HOOD(WIDUCD - H S 1 GATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the epPlicat or fum.c buildingawpanlsmtctxlwndlc hr,ammux mamnul HEATING UNIT CIO I(X),nXI BTU)
as defined by the Cul'eniwrMunicilwl Calc,CheMu 9.12,ad Inc Ilaltb end Safety -
Code,Sccdan25532(.0 IIITYFINGUNIT(OVER 100,00ll BTU) VVI`Illlnv
❑Yes Fl No VENTILATION FAN(SINGLE RESID) PAID
Dote BerettaI
Will the as contig mes.t building feliieabuse .Air Quson adMana which BOILER-COMP OHP OR 100.000 BTU)
emit
District? uus oat cwuvnunonna u def ad feline ROY Arta Air Quality Mavgemes TOTAL: ,
Dislnn' -
(]Ya Fl No BOILER-COMP(OVER 100.000 BTU)
I base rend the hmnNum,maenads rtquircmrnL under Chapter 6,95 M the Cal I. AIRCONDITIONER ISSUANCE DATE ,
axniv Health Pt Safety Calc,Seew.,25505,25533 and 1553of.1 uulvswtl that If de NEW RFSIDENI'IAl.MECH. SU,PT.
'building docs not currentlyMeca.4 dust it Is my repor Niity to noufY,lheavvpem
of the mryirtneas which must he met prior to issuance of a Certificate of Oo rs srncy.
Owneraeuln«iudegcnt Des TOTAL_ .ISSUED BY;
OFFICE �_
A0,401 P. CERTIFICATE OF INSURANCE CSR �E DATE;M MIDD/YY)
DEVCO-1 04/16/96 .:
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
vnooucER _
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
R. G. Speno, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
8900 Stevens Creek Blvd. #200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
pertino, CA 95014-3674 COMPANIES AFFORDING COVERAGE
Ronald G. Speno COMPANY
St. Paul Fire & Marine Ins.
PnPn.No. 408-973-9500 FU No.
INSURED
COMPANY
B Republic Ind. Co. of Calif.
Devcon Construction, Inc. COMPANY
Bret Sisney C National Union Fire Insurance
555 Los Coches Street COMPANY
Milpitas CA 95035 D
COVERAGESz.,
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PE RIO
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH IESPECT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED.BY PAID CLAIMS. -
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POUCY EXPIRATION
LTR DATE(MM/DD/YY) DATE(MM/DD/YY) OBITS
GENERALLIABILRY GENERAL AGGREGATE s2,000,000
A X COMMERCIAL GENERAL LIABILITY KK08300294 04/01/96 04/01/97 PRODUCTS-COMPMP AGO 12,000,000
CLAIMS MADE � OCCUR PERSONAL N ADV INJURY 1 1,000,000
X OWNER'S 6 CONTRACTOR'S PROT EACH OCCURRENCE 11,000,000
X Per Loc. Aggreg. FIRE DAMAGE IMyo lire) $ 100,000
MED EXP(My a pump) 1 5,000
AUTOMOBILE LIABILITY
A X ANY AUTO RR08300294 04/01/96 04/01/97 COMBINED SINGLE LIMB 11,000,000
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS (Per person)
X HIRED AUTOS
BODILY WJURY
X NON-OWNED AUTOS (Par ii
PROPERTY DAMAGE 0
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 1
ANY AUTO OTHER THAN AUTO ONLY: ......_. "' ....
EACH ACCIDENT /
AGGREGATE i
EXCESS LIABILITY EACH OCCURRENCE a 14,000,000
C X UMBRELLA FORM BE3092982 04/01/96 04/01/97 AGGREGATE 114, 000,000
OTHER THAN UMBRELLA FORM 1
B WORKERS COMPENSATION AND
ILffY STATUTORY LIMBS
EMPLOYERS'LAB
EACH ACCIDENT / 1,000,000
THE PROPRIETOR/ INCL 3519774 04/30/96 04
PARTNERS/EXECUTIVE /30/97 DISEASE-POUCV LIMIT 01,000,000
OFFICERS ARE: R E%CL IDISEASE-EACH EMPLOYEE 11,000,000
OTHER
A Rented, Leased & KKO8300294 04/01/96 04/01/97 SpecCause 100,000
Hired Equip. of Lose incl.theft
DESCRIPTION OF OPERATIONS/LOCATIOMNEHICLESISPECIAL ITEMS
•10 day notice of cancellation for non payment of premium
CERTIFICATE.HOLDER CANCELLATION ..
0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
. _DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH N CE SHALL I BE NO OBIJON OR LIABILITY
OF ANY KIND UPON TH ANY,R a 0 w ft P2 ENT Ty EB.
AUTHORQEDREPRESj�n
Ronald G1.ACORD'25-9 (3!93)' is 'ymA RO.CORPORATION 1893 r.
ASHESTEST 3747269 P. 01
. ASBESTEST, INC.
1550 Dell Avenue,Suite E CUWI) 1,CA 93008(408)374-7762 Fax(408)374-7269
DEVCON CONSTRUCTION May 8, 1996
565 LOS COCHES
MILPITAS, CA 95035 Job No. A-16213-96
ATTN: STEVE COWLES
PROJECT: 10600 NORTH TANTAU
JOB #9636
ASBESTOS IDENTIFICATION BY
POLARIZED LIGHT MICROSCOPY
Non-Fibrous
Fibrous Asbestos Other Fibrous Materials or
Sample Identification Minerals. % Materials. % Minerals %
• #1 12"X12" FLOOR TILE, NONE NONE SAND, BINDER,
PINK DETECTED 100%
#1A FLOOR TILE NONE ORGANIC BINDER, 95%
MASTIC DETECTED FIBERS, 5%
#2 12"X12" FLOOR TILE, NONE NONE SAND, BINDER,
BROWN DETECTED 100
#2A FLOOR TILE CHRYSOTILE, NONE BINDER, 90-95%
MASTIC 5-10%
#3 12'X12" FLOOR TILE, NONE NONE SAND, BINDER,
BROWN WITH CARPET DETECTED 100%
MASTIC ON TOP
#3A FLOOR TILE CHRYSOTILE, NONE BINDER, 90-95%
MASTIC 5-10%
A negative floor file result is not conclusive by the polarized light microscopy (PLM)
method. It is recommended that scanning electron microscopy (SEM) be used for
confirmation.
•
NSHESTEST 3707269 P. 01
• PAGE 2
A-16213-96
This test report relates only to the items tested. The materials were examined by
polarized light microscopy according to Environmental Protection Agency methods.
Reported asbestos percentages were estimated based on comparison to test samples
provided by the EPA. Samples will be stored for one year and then properly disposed
unless prior arrangements have been made.
Respectfully submitted,
ASSESTEST, INCORPORATED
A JWA v
RobertM. Kumagai
Microscopist
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