13110106CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10455 S DE ANZA BLVD
CONTRACTOR: ELEVEN WESTERN
PERMIT NO: 131 10106
BUILDERS, INC
OWNER'S NAME: BDC HAYWARD LP
2862 EXECUTIVE PL
DATE ISSUED: 03/13/2014
OWNER'S PHONE: 9255882200
ESCONDIDO, CA 92029
PHONE NO: (760) 796-6346
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL E]
{� p
( q3
CVS -COMM. T.I 15,000 SQ FT, RELOCATE NEW MAINT
License Class—S 1 O
ENTRY, & FILL IN EXIST. REMODEL BREAKROOM,
rrLic.#
//13aie,Wftte
RESTROOMS, NEW COOLERS, REMODEL PHARMACY
Contractor E�11� FILeS`�RN493"3
PHOTO
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $51975
erformance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 35917019.10455
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments.
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
ss Date: Y --
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
v �31
Signature DateAll
roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 255 25533,d5534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent 03 /3
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRIICTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state Taws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records,
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10455 S DE ANZA BLVD CONTRACTOR: ELEVEN WESTERN PERMIT NO: 13110106
BUILDERS, INC
OWNER'S NAME: BDC HAYWARD LP 2862 EXECUTIVE PL DATE ISSUED: 03/13/2014
OWNER'S PHONE: 9255882200 ESCONDIDO, CA 92029 PHONE NO: (760) 796-6346
❑ LICENSED CONTRACTOR'S DECLARATION
License Class j
Lic.# 1 3 � �d
Contractor EV{V,ev-_ DwI GhDate
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations\
1 have and will maintain a certificate of consent to self -insure for Worker
Compensation, as provided for by Section 3700 of the Labor Code, for
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, aided for
Section 3700 of the Labor Code, for the performance of the work foicfi this
v'
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
411
Date 5—
_11/e
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (See.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
a18.
Date
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
CVS -COMM. T.I 15,000 SQ FT, RELOCATE NEW MAINT
ENTRY, & FILL IN EXIST. REMODEL BREAKROOM,
RESTROOMS, NEW COOLERS, REMODEL PHARMACY
PHOTO
REVISION #I- INTERIOR LIGHTING ONLY.- ISSD OTC 5/6/2014
Ft Floor Area:
Valuation: $51975
APN Number: 35917019.10455 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 110 DAYS OF PERMIT ISSUANCE OR
180 DAYS ROM LAST CALLED INSPE TI_OfN.
Issued by: Date:_
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, l agree to remove all new materials for
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CONSTRUCTION PERMIT APPLICATION
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appllcaunn and the infirmluion I hu\ e { ided 1c correct. I have ad II Descripuon of N"ork ;uuf \enl} i1 is ac cur:ur !agree to comply With all applicable local
ordinances and Mate lawn rclaan¢ m l 1 ne construction I au ave presc 41% CS of Cupcnino lu enter the 11ho\e-identified propert\ for Inspection purposes.
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Signature of Applicant Agent:y ...-.__—__ Dale:
7
SUPPI_L'WNTAL INFORM ON REQUIRED
PLAN (IIF:CK TYPE
ROTTING SLIP
❑ (1{'F.R-THF.t'l)('VTF.R
LDING ..."RF{'IFN'
New SII) or Multifamily dwellings: Apply for demolition pernut for
-
existing, building(s). Demolition permit Is required prior to issuance of building
perm, for new building.
❑ ExPREAN
PLANNING PI. AN RF'.{'IF.N
Commercial lildgs: Provide a completed hazardous Materials Disclosure
STANDARD
U PUBLIC WORKS
firm if any Hazardous Materials are being used as part ofthis Project.
❑ LAR(:).
IRF OF
_ Copy of Planning Appro\al Lefler or Meeting with Planning prior Io
.� MAJOR
SANITARYSF.wFR D1tiTRl('T
submittal of Building Permit application.01
❑ FNVIRONAIFN'IALNF.AITD
14 0 1 p '`�/� Q1�-(yl)� �� �i 1 �13G1.I1✓1 �CAA.0 Bldg.aj)P ?()ll dnc rc•1'i.cvt! ()(S;'/'/ /
17
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CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a_)cupertinc.orq
CUPERTINO
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/7 REVISION DEFERRED
ORIGINAL PERMIT # (31 l o IGG
PROJECT ADDRESS y i '� V e A n t e, y, 1 V 1
APN #
OWNER NAME (1` O ` 1� � � � � (; f� I {% PHONE ^ 7 � � -� � /,
`t
E-MAIL
STREET ADDRESS , !
AA
CITY, STATE,ZIP
FAX
CONTACT NAME
PHONE E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER
❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSENUMBER LICENSETYPE
BUS. LIC#
COMPANY NAME
E-MAIL
FAX
STREET ADDRES
OW -e
CITY, STATE, ZIP
CA q 2G -Z -J
PHON�
` 6- �',3If
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
EXISTING USE
PROPOSED USE CONSTR
TYPE
k STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EX1STG
NEW FLOOR
DEMO TOTAL
AREA
AREA
AREA NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREATOTAL
DECKIPORCH AREA
GARAGE AREA: DETACH
[]ATTACH
9 DWELLING UNITS:
IS A SECOND UNIT []YES
SECOND STORY []YESBEING
ADDED? NO
ADDITION? []NO
PRE -APPLICATION [:)YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED BY?
TOTAL VALUATION:
PLANINING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
By my signature below, I certify to each of the following: I am the property owner or authorized agent tc a n the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
-� - -- G- -
Signature of Applicant/Agent:,.--= _ Date:
SUPPLEMENTAL INTFOR ATION REQ IAED
PLANCHECFCTYPE
_,ROT3TII�GSLIP • , r,
E
k s
New SFD or Multifamily dwellings: Apply for demolition permit for
ovER TlizrcouNrER'z
UILDINGPLAN RE«W
existing building(s). Demolition permit is required prior to issuance of buildingti
{ ° " u Y
permit for new building.
EarREss wv
�❑PiAxri�N�PLrrrltEVlEty
Z�
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
'IT❑ PUBLICRORKS r
_
form if any Hazardous Materials are being used as part of this project.
_
nr .
y
❑ :LARGES 4 � y r � ��,�,
❑ FitE DEPT ��� �� � ,� '�
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
❑r MAJOI�:� `.7�' �
❑ SAAITARYSESS'ERD15TRICT
;° ` } _� c : � . -
❑_, EI��IROIV114ENTAI HEALTH
31dgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FM -7 FEE ESTIMATOR - BUILDING DIVISION
imADDRESS:
10455 s de anza blvd
DATE: 11/15/2013
REVIEWED BY: Mendez
PC FEE ID
APN:
BP#: `3 /j b
`VALUATION: 1$51,975
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE:
IMTIPLNCK
PENTAMATION 1 M TI
PERMIT TYPE:
WORK
cvs- comm. t.i 1,195 sq ft relocate new maint ent & fill in exist. remodel breakroom restrooms new
SCOPE
coolers, remodel pharmacy photo counters, add stair to mezz
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
M (Tenant Improvements)
II-B,111-B,Iv,v-B
1,195
$2,857.18
IMTIPLNCK
$1,141.65
IMTIINSP
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,141.65
Suppl. Insp. Fee:Q Reg.
OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
TOTALS:
1,195
$2,857.18
7T
$1,141.65
MECH, HOURLY 0 Yes ' Q No =
PLUMB, HOURLY Q , Yes Q No
° ELEC, HOURLY : Q Yes (F)No
MISC ITEMS
Plan Check Fee:
,1.V.
$2,857.18
Li
Suppl. PC Fee: Q Reg. OT
0.0
hrs
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District etc)_ These fees are haled an the nreliminary information available and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11-053 Ef. . 7/1113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,857.18
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: Q Reg. OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,141.65
Suppl. Insp. Fee:Q Reg.
OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Con,mw fion TOA,.
0
Work Without Permit? Yes No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
E)
0
<'l FiCS-
Strom Motion Fee:
1BSEISMICO
$10.91
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$3.00
SUBTOTALS:
$4,012.74
$0.00
TOTAL FEE:
$4,012.74
Revised: 10/01/2013
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10455 s de anza blvd
FEE
DATE: 05/06/2014
REVIEWED BY:
MENDEZ
APN:
BP#:
'VALUATION:
Iso
PERMIT TYPE: Building Permit
$0.00
PLAN CHECK TYPE: Tenant Improvement
$0.00
PRIMARY Commercial Building
USE:
Permit Fee:
PENTAMATION
PERMIT TYPE:
1GENCOM
WORK
REVISION #1- INTERIOR LIGHTING ONLY.- ISSD OTC 5/6/2014
$0.00
SCOPE
PME Unit Fee:
$0.00
PME Permit Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addh 7 info.
FEE ITEMS I'ee Resolution 11-053 C " 7%1'131
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly Only? O Yes Q No
$0.00
1 hours Plan Check, Hourly
$139.00 ISTPLNCK
Suppl. PC Fee: O Reg. OOT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -.(E) Reg. O OTQ,Q
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
4
O
Work Without Permit? O Yes O No
$0.00
Advanced Planniih Fee.
$0.00
Select a Non -Residential O
Building or Structure
Strong Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$0.00
$139.00 TOTAL FEE:
$139.00
Revised: 04/01/2014
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: /0 55' S. Ac 4AIZf- /.3k vb
PERMIT # /3// 0/0
OWNER'S NAME: dDG
PHONE #
GENERAL CONTRACTOR:EL6V W&r,5, eA/%jv/1Pa-f
BUSINESS LICENSE #
ADDRESS: 21962 GXF?iu7/Vi6 It OeOND1O10X *2
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ontractor Signature
S'/3 —/y
Date
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: /C � 157n5- f' %C 4AJ1 AL V
PERMIT
OWNER'S NAME:'+
PHONE #
GENERAL CONTRACTOR:,�L Vf,A-1vVZ�Vi—F ^..%%L/�L�r",f%�
BUSINESS LICENSE#
ADDRESS:'27 (�; r�-yr r_ t` �'i /V) - ' �I I 111(
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
<�....._.,- 0-maer-leontractor Signature
- 1;;/
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets &Millwork
�j -7
Cement Finishing
f
Electrical
Excavation
Fencing
Flooring / Carpeting
gS
Linoleum / Wood
Glass / Glazing
Heating
i.
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
k
Roofing11
fi
Septic Tank
61
Sheet Metal
Sheet Rock
CA
Tile
t I
<�....._.,- 0-maer-leontractor Signature
- 1;;/
Date
HAZARDOUS MATERIALS CHECKLIST
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
CUPERTINO 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 - buildino@cupertino.org
PURPOSE
To minimize possible delays that would result for the Fire Department plan review, please complete the
following checklist to determine if an additional level of Hazardous Materials plan review will be
required.
MARK'YES' IF THE PROPOSED SCOPE OF WORK INCLUDE ANY OF THE FOLLOWING?
PLEASE MARK YOUR ANSWER WITH AN 'X' IN THE YES OR NO BOX ON THE SIDE
BELOW.
YES
NO
1. Use, dispensing, mixing or storage of flammable or combustible liquids or gases,
hazardous materials, etc.
IK
2. Battery back-up rooms or racks.
3. Propane tanks.
4. Gasoline stations with underground tanks.
5. Installation or replacement above ground or underground storage of liquid petroleum
products, liquefied petroleum gases, compressed natural gas, explosives or other
regulated hazardous materials.
6. Gas rooms for dentist, doctors or veterinarians.
7. Generators with back-up diesel or other fuels.
8. Large refrigeration systems.
9. Fuel cell systems.
10. Commercial pool systems.
11. Chemical Storage areas.
12. Flammable liquid storage.
13. Compressed Gases,
14. Dry cleaners.
15. Print Shops.
16. Auto Repair and Auto Body Shops,
17. Research and Development.
For any additional information regarding this checklist, please contact Hazardous Materials Specialist, Santa
Clara County Fire Department, at (408) 378-4010.
HaWat 2011.doc revised 03/07/11