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Hazardous Mater San Jose Fire Department <br /> Bureau of Fire Prevention <br /> SANIOS119 Storage System Pa Four N.Second St,Ste.1100 <br /> San Jose,CA 95113-1305 <br /> CAFrTAL of SEUCON VALLEY Phone:(408)277-4659 <br /> Associated Building Folder(Permit Folder/Permilk. C) Li -1 <br /> PRO2I5CT11%ClLJTy LOCAT1109' <br /> Busme,qs Name� oat Date: it 1 1411 1 02- <br /> Address: San Jose,CA,Zip: <br /> Neafest Cross Street: f9g-.es-r CAmkVia.L�e- Contact Personirride: Ph: 25) .5S&6 <br /> APPLI(�ANT-1 FOR' 00 <br /> .14 VA..0412:7�-m <br /> BusinessName: <br /> Mailing Address: ?0 BO-A 5Qq5& AM 51r00V City: skr,a*wLrr, State:C44- Zip: qq,531, <br /> ConfactPerson: And,(tlo fftwo- Title: lovi"afreevre-i M"arel <br /> Phone:(42D 8- or CILTJ -9ZL—- -/W1 e-mail address: <br /> 3--M X.- M; <br /> ,kt <br /> Business Name: <br /> MailingAddress: P0-r)i;:aQr0- Saff1oSV-.GA-Zn)- 6"V-44- CA clq�FID <br /> Contact Person: (nAa& ffkm!rkf� Tile: <br /> Phone:("—i q4;M --7wi or e-mail address: <br /> *San Jose City Business License Number. Expkafion J)ate: <br /> *Worker's Compensation Number. 5L�Al L?0,5ZV2 �Exptratior;Date.- 10 / *31 /03 <br /> *Stale Contractors License Number and Type: �;'51WQ2- Expiration Date. Q? / 'Al I_LLL�_ <br /> *If eKem2t.then contractor's information sheet must be submitted application. <br /> WORK PROPOSED (Select One) TYPE OF PROJ ECTISYSTEM:(Select One) <br /> Closure []Facility Partial Closure Hazard Compressed Gas/Cryogenic System Variance <br /> Repair E]Facility Full Cosure El inert Compressed Gas System Battery System <br /> New Installation D Alteration El Other Hazardous Material System(NOS) Metal Finishing/Plating Une <br /> D Removal X-Te-porary t/5 T-C,10 jvik- El Aboveground Tank/Piping System iliquid) Facility Closure <br /> Note Undergmund TankiPlpirig System or Vartanoe.must �LUnderground TankiPiping System Olquid) 0 L.P.G.Tank Piping System <br /> have ,dditi�al applications attached to this to". <br /> :-�SY-StEM.COMPONEMTS PRIMARY CONTAINEIZ SECONDARY CONTANIMENT <br /> :,rplze(Volume, Construction <br /> Hazardous Materials Stored Construction Material .I Size(Volurne'. <br /> Pipe Diam.,etc.) Material Pipe Diam:,etL� <br /> vp 1::� <br /> 2 <br /> 3 <br /> 4 <br /> I <br /> Attention Contractor: <br /> This permit is being issued pursuant to the requirements specified on the attached San Jose Fire Departiment Plan Check. It is your <br /> responsibility to post this document conspicuously at the job site prior to commencing work. You are to have an approved set of plans and <br /> San Jose Fire Department Plan Check available at the job site. You must contact our office to schedule all required inspections at least <br /> 48 hours in advance. This permit is valid for 180 days from date issued. The project must be completed by this date,unless poor written <br /> approval for extension is given by the San Jose Fire Department. <br /> APPLICANT'S NAME(Please Pdntl TITLE(Ploase Print) AEF,1JGAKT-S SIGNATURE DATE <br /> FIRE DEPARTMENT USE: <br /> Date �5d 8, Inspector's Comments <br /> Plans Reviewed ?Fo, <br /> Primarry Containment <br /> Secondary Containment <br /> Monitoring System jl=ti 1-7 <br /> Other. <br /> —0-Z <br /> Final Inspection wi&? A---- /ZA7/03 <br /> Fomi N.240-143(R-.1*2� Copies WHITE-Permit File PINK-Applicant HAA0 Copy-Job Site <br />