S1420 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL - Mgt NO. I
BUILDING DIVISION APPLICATION/PERMIT ......I NG-MECHANICAI' J 1420
BUILDING PROJECT IDENTIPIGQION
BUILDING ADDRESS
SANIIARY NO. APPLICA'l l N SUBMrl'I AL DATES
�71),i �
NNER'I NAME,: PHONE,: CONTRACTOR'S NAME LIC NO:
AciC G L, - - tl L nn 1573 NIC CONTROL#
CHITECTIENGINECR: LIC NO: ADDRESS: CISTCIS ❑
I
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PTLEA1H MECH
❑ ❑ Iff ❑
LICENSED CONTRACTOR S DI CLARADON QTY ELECTRIC PERMIT FEE
I by abnormal l I . a n a p - a: f Chapter 9(enamors ng JOB DESCRIPTION
Wci�Z w,NR r nM10)afn ni rens Ru. Jv tm.xronxcam ane m)hcenw it RESIDENTIAL:
p p P17RMIT ISSUANCE
10 c0. '.full f - I effect C 0 SFBWL ❑KITCHEN REMODEL
aUL Liven: Clv� - Lick APPLIANCES RESIDENTIAL - ❑ADDITION ❑PLUMBING RC PII'li
F Z to Dan. `t Cum vclnr ��
m6a ❑MULTIUNIT LI STRUCTURAL
ARCHITECTS DECLA TION
F N PANELS
Z_ 1 moranand my plans shall M:used as public mantas .MODIFICATION
OZ—p UPTO 2W AMPS ❑INTERIOR ❑CHIMNFYREPAIR
F•�.F.41 Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I0R)AMPS ❑BATH REMODHDREPAIR�DEMOLffIOIS
1 6 1 hereby affirm that 1 am exempt lrom the Contractor's License Lax for the
X 3 a U following ms,on.(Section 7031.5.Business and Pnrl'essinns Code.Airy city or c 1Y SIGNS I I F,C'.RICAL ❑Of HER
L'1
y whish q a Permit t :t t.alter, p demolish. p any mmeture RP a I ace Ins nt
F'u+p6 prm r ts i—entic,also mquimstM1 pplicam Fooliuto fl :'g rd autleacal SPECIALCIRC,IIUMISC.
Ew}� that he is licensed pt to the Provisions ofth Contractor's 1 c W '(Ch pmr9
(commencngwith Section Ilul)of D'timort 3ofrhe Brsihs,s, ad lrofussons Calc)or '1ISMV.METE OR POLE INST. - COMMERCIAL
a y o fg that he is exempt rbereGam and the basis for the alleged exemption.Any violation of El NEW BLOC/ADDI'[ION ❑DEMOLITION
fa1�m Sectio 7031.5 by any applicant for u permit subjects the applicant)a civil penalty of POWER DEVICES ❑TENANT ❑FOCI)SERVICE
not mare than five formed dol lam($50), IMPtVAEMAI
'
E=0 ❑ I.as melanins,property.or my employees with wages retheir mic comperenian, SWIMMING POOL ELECTRIC ❑OT
F. w 11duthuwark,:mdnesn'on, anolimm�dalt)ruffeclfixrsale(Sec.70441l uamess
W-•m and probessinns Cafe:The Contractor's License Law aces not apply to son owver,of OUTLETS-SWITCHES-FIXTURES
proln�rly who bailds or ingnuvee Ncreun,and who does such work himself or through
his employees,p Jed that such p c .intended offered for NEW RESIDENTIAL ELECTR SQ IT.
de It,h ll funding l p r sold ill y i pl f n the SISQ.FT,
wn b ld will he,,N burden (P partial, dill hold P ra par
Inst f'17. TOTAL
E]1, frhep Arty rlus lyemotional, 'rhl d r'tlarsI.
con Wet the project(S 7614.Rai m— J 14 f v,me,Cale)The Conmamors L
axe Law dots na nUlymr an owneof pmpcny who huilds or impmvcs thercnn.:.ad QTY. PLUMBING PERMIT PEE
w'ho somencts for such pmjectx with a eontrwtorp)licensedprasunm to the(onrmnar z
Ltcvroc Lar'. PISRMI'I ISSUANCE
I am exempt under Sec. .B&P C for this rerun
ALTER-DRAIN R VENT-WATER(1'-A)
net Date
WORKERS COMPENSATION are
UIiCLARATION RACK PLOW PROTECT'.DEVICE
I hand%aflkns under penally of perjury enc of rhe inllowsure for Workers
Co
� Ihave andwie for maintain 3703 of Consent to self
Laborode,fitu the Walkers Qtmf the DRAIRS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONSTRUCTIfIN
smirk,as Provided forbySection 3710 of the Lehrer Code,for the Nrf rnwncu of the
work for which this pemdt is issued FIXTURES-PER TkAv
11�11 hove ono will lode,fon Work...tenseCanalo stionthe
Insurance, h o7ulaihis prrJ by Section Q]W of Nc WMrt Cala far the peRormance of the work lm which this pcmtit is issued. GAS-ISA.SYSTEM INC.q DO ILL OCC.GROUP N'N
My Work.' Curinaomi 9W `'ca rtic rand Policy.tn p
Carates ramp n.a ranPolicy Nm � rPG1(5 GAS-PA.SYSTIN OVER 4(CA)
CHR'I'IF1CATE OF EXEMPTION FROM WORKERS' GREASFJINDUSTRh WASTEINTERCEE'1 OR
COMPENSATION INSURANCE BUILDING DIVISION FE S
(Thlesdton need not M1e completed dim,panni.is far one lmndreddollns(SIAB GREASETRAP
ar le".) PLANCIIECK FI?IC
I verify that in the performancc of work for which this permit is issued.l shall SEWER-SANITARY-STORM E.A.200 Pf.
not employ any past n
many
nner nn as to lac( embjeel ei.M1e Worker,Counter- ENERGY PI?FEE".Z sation laws of California.DaWATER HEATER WNENUliLECTR
O O A,plicaar GRADING FEF,
'Z N NOTICE TO APPLICANT:If.arm,making this C,mficum of Himari tion,you should WATER SYS ENFTREATING SOILS FEE
a heconm suw a
bject rc Walker.Coegas
nsup
don mvlxiens it the LuMa Cola you must
W fouhwiN comply with such provisions or this Permit shall be deemed revoked WAFER SERVICES
Q
7z CONSTRUCTION LENDING AGENCY NEW ItE11DLNTIALI'LMR. SQ.Fp PAID Date Receipt
U O 1hatch,offinum hthe,,is a romancing lending agency ref Ne arfnrmuace of
LFy (ti the work fill which Nix pmnit in issued(Sec.30)9.Co.C.)
O
r OlAh:
U lender's Name 1 OTA1,
"
U Lenders Address ' : L'
1 ecnify that I have mai his application and slate that he arawe intermitting is BUILDING PEE
F m concur.l agree m ennrply wilh ell city an l cmmty on inancu ane seem l aos Drilling to QTY. MECHANICAL PERMIT FEE
U z buildupeca,maxnan.and hereby amhorim mpremmmives ofthis city to rnmruporrhe SEISMIC FEIi
above........toned property or inxpenlen purpnev. PERMIT'ISSUANCE. ELECTRIC PEE
(We)agree m vave,indemnity and keep famdesx the Fay of Cupertino-It-'
liubiliticsjnogmenta.mstn urea expenses which may in any wry utt:me nFairvxl said City Ar ER OR ADD TO MECH. PLUMBING FEF,
in omcqutmer of Nc Fnmir,of Nis permll.
APPLICANT UNDERSTANDS AND WILL COMPLY WHII ALI.NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FTSE
SOURCE REGULATIONS.
AIH HANDLING UNIT(OVER IILOIX)CFM) CONSTRUCT ION'TAX
Signature ill AppicaMCommtor Dam EXHAUST HOOD(W(DUCI') HOUSING MITIGATION FEE
HAZARDOUS MAI(RIALS DISCLOSURE
Witte applicant or future Flight,acupam smnor handle havvJt)usnnmriul HEATING UNIT CFO 110,000 BTU)
us dcline❑d h,I llm Cu nrtno Mr Eipal Cud,Chnpmr 9.12,.,,it IT
the enld, ,to Safety Y HEATING UNIT(OVER 100.000 If I'ED
Craig.Sateen 2592(x)7
VENTILATION CAN(SINGLE RE-SID) I I
Uac Ncccipr#
Will the applicant or future building occupant use equipment or devices which RUDER-LER COME(3HP OR I BELABI B FBI
mit ha a fou.air contaminants as defined by the[lay Area Air Quit try Management MAY 2 1913 4.'
Diane" BOILER-COMP(OVER 100,000 BTU)
E]Y,,
.wants mntert u rs made,Clwmr6.95af Ne Cali- AIR CONDITIONER ISSUANCE DATE
I five wall Balm/
.wants
forma Health&Safcry Code,Sections 25515.25533 and Z5534.I understand that it the NEWRESIDINTIALMMi. SQ.FT. BY
butldtngdem nutcwhich bustmmnant our itixmycenfa Ceni mnotifythe occupmn
of Ne mquiremenN xhich must M:nwt pastas issuance nfa Cenificme of(tcupmcy. �' W
Owner ocamhorese l ugenr Dale TOTAL ISS, It
OFFICE
STATE ' eo: BOX 807, SAN.•FRANCISC0,Ck9410'1 0807'_'
`COMPENSATION - - '•
•CN
r V%N`D „ CERTIFICATE OF' WORKER& COMPENSATION. INSURANCE
t.
=r * •-?- c 't ,v., Fr < ra,POLICY NUMBER 1516265 - 99
1
-ISSUE DATE-y 04 20-98�1 lema x .. " r te= CERTIFICATE`EXP 'IRES04 20-00
"• y C'hTY OE ,CUPERTINOp 1 gvy 4 '7
JOB ALL CALI FORNIA;OPERATIONS.
0 BLDG .;I NSPTr .rDEPT : - .z,.
r 1030M TORRE AVE
'CUPERTXNO`"CA 950,14
v.� ..aN-.Pt Y� S" d•.wr 'k�. .,. �..">- r .l>i f - r .� ��rr _ • '
t'`4�i t•r • .` ;. 7J .:^a +r 4L� r ,."`
,a;This is�to'ycertify tha0wer have issued.a,`valid,Workers'"Compensation,.msurance,policy in^a.form.approved:by,,the.-
t It ra Insurance Commissioner:,to the employer named below for the-policy penod•ihaicated
h ti ';;y 94'• ;, r�u,"r : .. ,��. ,xr.,, -; €.uu. r .. Al" .{. . c.
�� �a r." tj '• '.. .k -` ,•(t> .•.. '-
,This po11'-is not subject to caocellatiomby the Fund except,uponlodays.';advancegwritten notice°to. the-employer -
r o Y $' S rP - vAy"'^ p ' 'k.`F .S ,,y t b^• { � r « h . t 4 -
,,,.We will also give you l0�days,advance notice should+this policy be-�cancelled�pnor to is normal expiration -
•?'This"certificate..ofrmsurance rednou an„insurance•policy:an"i does;not,amend, extend or- alter the coverage afforded: -
4•+by the,;poljcies hsted?herem'Notwithstanding•anyt�requirement`term; or,'condition,ofl,any"contractor,,'other document; -
1 °-,with•respect toawhich�this`+certificate.of5'ihsurancec ay beiissued-or:may,pertain then insurance,afforded:by.the
policies describetd hereinpissublect to all^the terms exc lusons:and condition: of zgsuchspohaes t.
e�
-
^GG11
•^' t3'1>:} r't t { �w. eY ,< t s €s; x ' t' i PRESIDENT
i Y .} `?• .x ,' x.
�ftl` apt re"�`
EMPLOYER!S LIABILITY LIMIT INCLUDING'DEFENSE COSTS 51 000;000 00 PERI OCCURRENCE'.
P rrl. j a...41
m,. ..
14 ll�
t•.ti �{ ♦ tit' y 3r. y-
ntA
£, EMPLOYER- ', -' ` v '"'- •, LEGAL NAME''
x ,
N WATER HEATERS• ONLY,_I NC.. WATER HEATERS ONLY, INC.
500 AIRPORT BLVD: #,240:
BURL I NGAME CA: 940.107, y
• t ,
PRINTED: 03-18-99. P0410'
DOCUMENTTHIS D - -•
ACOam CERTIFICATE OF LIABILITY INSURANCEgID GB DATE(MM(DOMY)
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
4670 Willow Road, Suite 250 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
canton CA 94588 INSURERS AFFORDING COVERAGE
ne925-463-9672 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 94010
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.
LTR 7 TYPE OF INSURANCE POLICY NUMBER DATE MWOD DATE MM/DD LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $
CLAIMS MADE ❑OCCUR MED EXP(Anyone person) $
PERSONAL 8 AOV INJURY $
GENERAL AGGREGATE $
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-WMP/OP ADD S
POLICY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO —
ALL OWNED AUTOS BODILY INJURY $
(Per person)
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY $
(Per accident)
NON-OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG S
EXCESS LIABILITY EACH OCCURRENCE S
OCCUR F-1AGGREGATEMADE AGGREGATE $
4
DEDUCTIBLE S
RETENTION $ S
WORKERS COMPENSATION AND X TORY LIMBS ER
A EMPLOYERSLIABILITY 151626598 04/20/99 04/20/00 E.L.EACH ACCIDENT $ 1,000,000
E.L.DISEASE-EA EMPLOYE S 1,000,000
E.L.DISEASE-POLICY LIMIT S 1,000,000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
All California Operations .
CERTIFICATE HOLDER N ADOMONALINSURED:INSURERLETTER: CANCELLATION
CUPER-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
•F 30 DAYS WRTREN 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 KING UPON THB4NSRER.ITS AGENTS OR REPR ATIVES.
Jane Ann e
ACORD 25-S(7197) &1ACORD CORPORATION 1988