29815APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
PERMITNO, r
29815 r�
BUILDING PROJECT IDENTIFICATIONo
V
BUILDING ADUkE55'
/7,3 �Tfl F �� /Z
SANITARY NO.
[PPI,ICATION SUBMITTAL DAT
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OWNER'S A ''O, PN�_�/ /eX:
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❑
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ARCHITF.Cf/ENGINEEN: LIC NO:
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CONTACT. PHONE :
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUM MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am Earned under provisions of Chapter 9 (commencing
wim5ection7000)of D1,msn3ofthe himme.sand Professions Caie,andmenu
ylicis
in full forte ana affaT's _ _
License Class of Lic. p
Date f Corona "'I'%Z(( /Fr*b
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTIO
R IDENTI
[ISFDWI. C1 KITCHEN REMODEL
❑ADDITION PLUMBING RE -PIPE
El MULTI -UNIT []STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REh DEI/DEMOLITION
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
ARCHITECTS DECLARATION
understand my plans shall be uue a public .cord.
PANELS
UPT02WAMPS
Licensed Professional2011
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
Wo AMPS
OVER IWOAMPS
SIGNS ELECTRICAL
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which reclaims a peon, n, emsearact, abcr, improve, demolish. or repair any immune
prior to its issuance, also "mics the applicant for. such Permit o file aligned statement
the' he ie liccnacl porn ant to the provisions of the Contractor's License taw (Chapter 9
❑OTHER
p{br s S
SPECIAL CIRCUIT/M ISC
'11EMH METER OR POLE INST.
COMMERCIAL
❑NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑FOOD SERVICE
(commencing with Section 7000) of Division 3 of the Business and professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
not man than by hundre donars(SS e). suhjeets tM applicant mucivil penalty.(
not more than Eve hundred dollars (SSW).
POWER DEVICES
SWIMMING POOL ELECTRIC
❑ Las owner of the propeny. or my employees with wages as 0cirsolecompomotian.
IMPROVEMENT
will do the work, and the strvaurc is nm imendcd or offered fnnalc (Sec. TIN4, Busincs
❑ OTHER
OUTLETS—SWITCHES—FIXTURES :;
and Profession, Cade: The Contractor's License taw does not apply to an owner of
property who builds or improves thereon, and who dues such work himself or Through
his own employees, provided that such improvements are not intended or offered for
NEW RESIDENTIAL ELECTR SQ FT`.
sale. If. however . the building or improvement is sold within one year of completion,rhe
nerbuilder will have the burden of proving that he did not build er impnwe for par-
s `\
SQ. FT IF OORAREA7111Q
pose ofsole.).
❑ Las owner of the propeny, ant exclusively contracting with licensed centmetmo m
��TO
construct the project (See'. TDiq Business and Pisfession.s Code:) The Comm nor's Li-
linmeLaw does notapply manawserofpmpen, who builds or impasses merean,and
who contracts tors.ch posed, with .'mamwor(s) Ba.aw Personal to the Cantmaora
\�
QTY. PLUMBING PERMIT FE
License taw.
❑ I am exempt tinder Sec , B & P C for this ream,
PERMIT ISSUANCE r
owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm
rot under penalty rperjury one of the following detlaat C
1 have and will maintainit eCertificate7W of Convert Code, for
Worker's Compmr
wortas provided for mi Section d. of the labor Code, for the performance of the
or for which this permit is issued.
w 1have andLawillmaintainhe parol Coreoftntinnrkfor himrequired by Sarson
3 of the laborCMe.InnM1e performance of the work for which this permit is issued.
My Worky" gpcn_yt�ipnlns_pcc c rant Policy JWtbe .
Cartier: CC�, GG 'l/TF�yiiLL""..7/ii N1P Policy No.: C..�
CERTIFICATE. OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ifthe pemdt is for one hundred dollars ($1 00)
,r Icxs.l
I certify that in the performance the work far whi,h this permit is iswed.I shall
not employ any pe n in artygsanner sn as to becomemhjatmNe Workers Compere
O� .,alio. law. !
z 0 Applic t
N NOTICE TO APPLICANT: If. .]let nuking this Certificate o' semptim, you should
a; become subject to the Worker's Compensation provisions of s e Labor Code, you arum
I'unhwith comply with such provisions or this permit shall he deemed revoked.
Uj
FL La
z CONSTRUCTION LENDING AGENCY
U O (hereby affnn that there is u construction lending agency for the performance of
V. F the work fill which this permit is issued (Sec. ROD, Civ. C.)
Q U Under's Name
Lenders Address
Fy 1 cenlfy that I have mad this application and state that the above Information is
N correctl agree to comply with all city and county ordinances and state laws relating m QTY
Uz building construction, and hereby authorize repmsentatives of this city to wterupenthe
above-bacra a nd Property for inspection purposes.
IWe) agree 4t eeve, indemnity and keep humUess the City of Cupertino against
Iiabilitiez,juJgmcros,ms¢and eapcnzen which may in my way ticcn¢again.q as City
in nze,imee of the granting al this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applili m/Contraemr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store rr handle hazardous material
as der cdoy the Cupenino Municipal Cola Chapter 9.12, and the Health and Safely
Cade, Session 25532(x)?
❑Yes ❑Nu
Will Ne applicant or future building occupant use equipment or devices which
etnit hataT'nus air contaminants as defined by the Buy Area Air Quality Management
Dimon?
❑Yes ❑No
I have read the hazardous matedala requirements under Chapter 6 95 of the Cali -
forms Health & Safety Calc. Sections 25505, 25533 amt 8534. 1 understood Out if the
building does not urmmly have a tesnt, that it is my responsibility to roti fy the occepunt
of the requirements which must be met prior to issuance of a Cenificate of Occupancy.
ALTER—DRAIN & VENT— WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS — FLUOR, ROOF. AREA, COND.
FIXTURES — PER TRAP
GAS—G. SYSTEM -I INC. 4 OUTLETS
GAS —EA.SYSTEM-OVER 4EA)
GREASEONDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER—SANITARY—STORM EA, 2110 FT.
WATER HEATER WIVENT/ELECTR
WATER SYS TEM(D EATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ, FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER IBOW CFM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO IRO,f do) B'TO)
HEATING UNIT (OVER IINI,WO BTU)
VENTILATION FAN (SINGLE RESID)
BOILER —COMP (3HP OR 1 W.OW BTU)
BOILER —COMP (OVER 1 W.0sk BTU)
AIR CONDITIONER
NEW RESIDENTIAL NECK SQ. IT.
OFFICE
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Rera,a#
BUILDING FEE
FEC
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
I CONST RUCTION TAX I
HOUSING MITIGATION FEE
PAID
Date Recdipt#
u I 111!PU v tCE DATE„
T7
W.QpP DESTROYING PESTS AND ORGANISMS INSPECTION REPORT
\ This is an inspection report only -- not a Notice of Completion
ADDRESS OF PROPERTY INSPECTED
95014 IC43 T03/11/96 NSPECTION P9
ANTIQUE TERMITE, INC. Affix stamp here on Board copy only
684 South Second Street A LICENSED PEST CONTROL
San1(ISC,CA95111 OPERATOR IS AN EXPERT IN
HIS/HER FIELD. ANY QUESTIONS
(408) 995-6300 (408) 995-0517 FAX RELATIVE TO THIS REPORT SHOULD
BE REFERRED TO HIMMER.
REGISTRATION B 'PR1187 REPORT A 8329A STAMP R 3052179T ESCROW p
ORDERED BY: NILE NORTON 1173 STAFFORD DRIVE CUPERTINO CA 95014
REPORT SENT TO: SAME ABOVE AND BELOW
PROPERTY OWNER: NILE NORTON 1173 STAFFORD DRIVE CUPERTINO CA 95014
PARTY IN INTEREST:
ORIGINAL REPORT N LIMITED REPORT [3 SUPPLEMENTAL REPORT [3* REINSPECTION REPORT E]
•gtalgnN Date
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TWO STORY SINGLE FAMILY DWELLING
GENERAL DESCRIPTION: t ,WOOD
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�. INSPECTION TAGS: ARTF 12-14-93
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5
1. SUBSTRUCTURE AREA See IA -1C
2. STALL SHOWER See 2A -2E
3. FOUNDATIONS
4. PORCHES -- STEPS
5. VENTILATION
6.ABUTMENTS See 6A
7. ATTIC SPACES See 7A
8.GARAGES - See 8A
9. DECKS -- PATIOS See 9A
10. OTHER -- INTERIOR SeelDA-lOD
11. OTHEREXTERIORSeel]A-11E
�— DIAGRAM AND EXPLANATION OF FINDINGS (This report is limited to structure or Structures shown on diagram)
" UlAGRAM lb NUl''1'U bCALiix*w*
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IECE� V ED
APR 3 0 1996
BLDG. INSPECTION DEPARTMENT
CITY OF CUPERTINO
FRONT
Inspected by DEAN R. MISNER License No. FR 22335 Signature
NOTE: Questions or problems concerning the above report should be directed to the manager of the company. Unresolved questions or problems with
services performed may be directed to the Structural Pest Control Board at (213) 897-7838, (415) 557-9114, or (916) 263-2533.
You are entitled to obtain copies of all reports and completion notices on this property filed with the Board during the proceeding two years upon
payment of a $2.00 search fee to: The Structural Pest Control Board, 1422 Howe Ave., Ste. 3, Sacramento, California 95825-3280.
4th PAGE OF STANDARD INSPECTION REPORT ON PROPERTY AT:
• 1173 STAFFORD DRIVE CUPERTINO
BLDG. NO. STREET CITY
3052179T 03/11/1996 8329A
STAMP NO. DATE OF INSPECTION CO. REPORT NO.
SUBSTRUCTURE:
Item 1B:. As outlined in item above, Drywood Termites were noted.
RECOMMENDATION: In conjunction with the Structural Pest Control Board,
remove or mask over all accessible Drywood termite pellets. Note: Since it
is common for pellets to sift down over a period of time due to the
structure setteling and other insect activity, our bid is for removing and/
or masking one time only.
****** This is a Section 1 Item ******
Item 1C: Minor cellulose debris (wood scraps) was noted over the subarea soil.
RECOMMENDATION: Remove and dispose of all the cellulose debris of a rakeable
size.
OIL St
W\
M 2A: Tile
and backing of tl� upstairs master bathroom stall shower was noted
deteriorated fr�n fungus and/ or excessive moisture.
r.
RECOMMENDATION: Remove existing tile and backing. Remove fiberglass pan,
rapair;w. If necesssary chemically treat exposed subfloor with a
registered fungicide (coppergreen). Reinstall fiberglass pan, new moisture
resistant sheetrock and new standard grade ceramic tile set in mastic
throughout the 3 wall stall shower. Note: If it is found that fixtures are
deteriorated or no longer usable, additional funds will be required to
complete repairs. If a plumber is found to be necessary or if damage is
found to extend into previously inaccessible areas, a supplemental report
will be issued. See contract regarding our guarantees on caulkings and
grouts. This is an owner maintenance item and Antique Termite cannot be
responsible for damages that may occur due to lack of maintenance. All
warranties will be void if the shower is used within 24 hours of its
installation. Tile selections can be made at Downs Ceramic Tile,2090 Old
Oakland Road, San Jose. Selections must be made at least five (5) days prior
to scheduled repairs. All upgrade charges must be paid for at the time of
the selection.
****** This is a Section 1 Item ******
Item 2B: In conjunction with Item above, upon completion of repairs, the following is
• recommended:
RECOMMENDATION: Owner to contact other trade to reset or replace the
enclosure and guarantee same. Note: Due to the method of enclosure
installation, shower enclosure may be damaged during removal.
****** This is a Section 1 Item ******
11
ANTIQUE TERMITE, INC. --- License Mai. PRI 187
;[Sh -PAGE OF STANDARD INSPECTION REPORT ON PROPERTY AT:
• 1173 STAFFORD DRIVE CUPERTINO
BLDG. NO. STREET CITY
3052179T 03/11/1996 8329A
STAMP NO. DATE OF INSPECTION CO. REPORT NO.
STALL SH WE
Item 2C:. Tile and backing of the upstairs hall bathroom tub shower were noted
deteriorated from fungus and/or excessive moisture. (3 wall mastic)
RECOMMENDATION: Remove existing tile and backing. Pull tub and -r=Pa'
if necessary chemically treat exposed subfloor with a
registered fungicide (coppergreen). Reinstall same tub, new moisture
resistant sheetrock and new standard grade ceramic tiles throughout the 3
wall tub shower set in mastic. Note: If it is found that the fixtures are no
longer usable or are deteriorated, additional fuixds will be required in
order to complete repairs. If during the course of our repairs damage is
found to extend into previously inaccessible areas, a supplemental report
will be issued outlining findings and costs for any additional repairs. No
plumbing repairs or remodeling is included in this estimate. See contract
regarding guarantees on caulkings and grouts. This is an owner maintenance
item and Antique Termite cannot be responsible for damages that may occur
due to the lack of maintenance. Antique Termite will void all warranties if
the shower is used within 24 hours of its installation. Tile selections can
• be made at Downs Ceramic Tile located at 2090 Old Oakland Rd,San Jose,
selections must be made five (5) days prior to repairs.
****** This is a Section 1 Item ******
Item 2D: In conjunction with Item above, upon completion of repairs, the following is
recommended:
RECOMMENDATION: Owner to contact other trade to reset or replace the
enclosure arra guarantee same. Note: Due to the method of enclosure
installation, shower enclosure may be damaged during removal.
****** This is a Section 1 Item ******
Item 2E: Caulking and grout was noted to be missing from the tile of the tub/stall
shower in the downstairs stall shower bathroom.
RECOMMENDATION: Owner to recaulk and regrout the as needed and maintain
during the course of routine home maintenance.
****** This is a Section 2 Item ******
ABUTMENTS:
Item 6A: Hollow columns exist at the front of the structure and the interior wood
members area inaccessible for inspection. There is no outward evidence of
infestation or infection present at this time.
RECOMMENDATION: Install test holes into the wood to allow for FURTHER
• INSPECTION of the interior wood members at which time a supplemental report
will be issued outlining findings and costs for any additional repairs or
treatments. Bid for this will be provided upon request from interested
parties.
****** Unknown Further Inspection Recommended ******
ATTIC:
I NOTE: The attic was found to be insulated. The inspection of the attic area
• is limited to the visible wood members only. This note is for general
:information purposes only.
Item 7A: ,Water stains were noted to the wood members of the attic indicating past or
present roof leaks.
RECOMMENDATION: Owners to engage the services of a licensed roofer to
isurvey and make necessary repairs to correct this condition.
****** This is a Section 2 Item ******
ANTIQUE TERMITE, INC. --- License No. PR1187
6th •.PAdE OF STANDARD INSPECTION REPORT ON PROPERTY AT:
• 1173 STAFFORD DRIVE CUPERTINO
BLDG. NO. STREET CITY
3052179T 03/11/1996 8329A
STAMP NO. DATE OF INSPECTION CO. REPORT NO.
GARAGE:
Item BA:. The garage inspection was limited due to occupant storage at the perimeter
walls.
RECOMMENDATION: Upon removal of the storage by the occupant or owner, a
FURTHER INSPECTION will be performed at which time a supplemental report
will be issued outlining findings and costs for any additional repairs. No
charge if performed during time of other repairs.
****** Unknown Further Inspection Recommended ******
DECKS - PATIOS:
Item 9A: At the request of the owner, the rear deck and hot tub gazebo was not
inspected.
RECOMMENDATION: If interested parties desire this area to be inspected,
Antique Termite will further inspect. Issue supplemental report of findings
and costs for repairs, if any.
****** Unknown Further Inspection Recommended ******
SER - INTERIORS:
Item 1OA: Water stains and damage was noted to the sheetrock at the ceiling in the
downstairs office. It appears to be caused from a past leak from the
upstairs bathroom tub plumbing.
RECOMMENDATION: Remove damaged ceiling. Replace with new materials. Cwner
to contact other trades to spray acoustical ceiling as necessary.
****** This is a Section 1 Item ******
Item 1OB: Fungus and/or excessive moisture has damaged the upstairs hall bathroom
floor.
CJ
RECOMMENDATION: Remove existing floor cover and damaged ur)derlayment. If
necessary, treat exposed wood members with an RDA Registered fungicide
(coppergreen). Install new urderlayment where removed and new standard grade
no wax linoleum to the floor. Reset the existing toilet on a new wax seal
properly bolted to the floor. NOTE-. If damage extends into inaccessible
areas, a supplemental report will be issued as to the findings and
additional repair costs. Linoleum will be of neutral color and standard
grade based at $ 7.50 per square yard. If desired, selections can be made at
S&G DISCOUNT OUTLET, 505 SOUTH MARKET STREET, SAN JOSE. Selections must. be
made at least five (5) days prior to scheduled repairs. Upgrade charges must
be paid for at the time of the selection.
****** This is a Section 1 Item ******
1bC: Water stains were rioted to the ceiling indicating past or present roof
leaks.
RECOMMENDATION: Owner to contact a licensed roofer to survey and repair as
necessary.
****** This is a Section 2 Item ******
ANTIQUE TERMITE, INC. --- License No. PRI 187
ith PAGE OF STANDARD INSPECTION REPORT ON PROPERTY AT:
• 1173 STAFFORD DRIVE CUPERTIN0
BLDG. NO. STREET CITY
3052179T 03/11/1996 8329A
STAMP NO. DATE OF INSPECTION CO. REPORT NO.
OTHER - INTERIORS:
Item 10D:' Fungus and/or excessive moisture has damaged the upstairs master bathroom
floor.
REOOtMENDATION: Remove existing floor cover and damaged underlayment. If
necessary, treat exposed wood members with an RDA Registered fungicide
(coppergreen). Install new underlayment where removed and new standard grade
no wax linoleum to the floor. Reset the existing toilet on a new wax seal
properly bolted to the floor. NOTE: If damage extends into inaccessible
areas, a supplemental report will be issued as to the findings and
additional repair costs. Linoleum will be of neutral color and standard
grade based at $ 7.50 per square yard. If desired, selections can be made at
S&G DISCOUNT OUTLET, 505 SOUTH MARKET STREET, SAN JOSE. Selections must be
made at least five (5) days prior to scheduled repairs. Upgrade charges must
be paid for at the time of the selection.
****** This is a Section 1 Item ******
OA&ER - EXTERIORS:
em 11A: Stucco cracks were noted at various areas of the structure.
RECOMMIIIDATION: Owner to seal and maintain the stucco cracks in the areas
indicated on the diagram.
****** This is a Section 2 Item ******
Item 11B: Gutters were noted to show signs of seepage.
RECCPWNDATION: Owner to contact other trades to correct the gutters.
****** This is a Section 2 Item ******
Item 11C: Drywood Termite riddeling noted to the 2x4 at the roof eave.
RECOMMENDATION: Fill with a quality wood filler. Owner to paint. See LA
and 1B for treatments.
****** This is a Section 1 Item ******
Item 111): Antique Termite does not inspect roofs.
RECOMENDATION: Should interested parties desire further information on the
condition of the roof, Antique Termite recommends interested parties contact
a licensed tradesman to inspect roof.
****** Unknown Further Inspection Recommended ******
Item AE: NOTE: A building permit will be obtained to perform repairs. Antique
• termite, inc. will charge $250.00 to cover the building permit fee and
necessary inspections. Should the owner or agent wait at the property, the
fee will be reduced to $100.00.
****** This is a Section 1 Item ******
If it is found that during the course of repairs, damage and/ or infestation
is found to extend into previously inaccessible areas, a supplemental report
• will be issued outlining findings and costs for any additional repairs or
treatments.
ANTIQUE TERMITE, INC. --- License No. PRI 187
CERTIFICATE OF INSURANCE
ISSUE DATE
-
12/18/95
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Sedge?ck„James of California, Inc.
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
7555 Thi rd'Street
e 100
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
amento, CA 95818
16) 444-9520
COMPANIES AFFORDING COVERAGE
COMPANY A California Insurance Company
LETTER
LETTER COMPANY B Coregis Insurance Company
INSURED
Antique Termite, Inc.
dba M.R. Meek General Contractors
684 S. Second Street
COMPANY C
LETTER C. E. Heath Compensation
San Jose, CA 95112
CLETTEROMPANY D
COMPANY E
LETTER
COVERAGES
THIS IS TO CERTIFY THAT 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 OFANY CONTRACT OR OTHER DOCUENT WITH RESPECTTO 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
LTR
TYPE OF INSURANCE
POLICYNUMBER
POLICYEFFECTIVE
DATE
POUCYEXPIRATION
DATE
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
= CLAIMS MADE a OCCUR.
OWNER'S & CONTACTOR'S PROT.
PC913-2698
10/5/95
10/5/96
GENERAL AGGREGATE
$ 1,000,000
PRODUCTS-COMP/OP AGG.
$ 1,000,000
PERSONAL 8 ADV INJURY
$ 500 000
r
EACH OCCURENCE
$ 500,000
FIRED AMAGE(Anyone Are)
$ 100,000
MED. EXPENSE (Any one Person)
$ 5,000
AUTOMOBILE
LIABILITY
ANY AUTO
PC913-2698
10/5/95
10/5/96
COMBINED SINGLE
LIMIT
$ 500,000
X
ALL OWNED AUTOS
BODILY INJURY
(Per Person)
$
SCHEDULED AUTOS
X
HIREDAUTOS
X
BODILY INJURY
(Per accident)
$
NON -OWNED AUTOS
GARAGE LIABILITY
PROPERTY DAMAGE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
UMBRELLA FORM
AGGREGATE $
OTHER THAN UMBRELLA FORM
C
WORKER'S COMPENSATION AND
EMPLOYERTLIABILITY
C 000241301
10/1/95
10/1/96
X
EACH ACCIDENT $ 1,000,000
DISEASE -POLICY LIMIT $ 1,000,000
DISEASE -EACH EMPLOYEE IS 1,000,000
OTHER
I
DESCRIPTION OF OPERATIONSILOCATONSNEHICLEWSPECIAL ITEMS
** A 10 day Notice of Cancellation shall apply in the event of non-payment of premium. **
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL MAIL 30 DAYS
City of Cupertino
Building Dept
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
10300 Turre Avenue
Cupertino, CA 95014
AUTHORIZED REPRESENTATIVE