01030091 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT ' CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERIOD INO
21100 CANYON OAK WAY, ACME & SONS ..SANITAT Onl/ELECTRI01.030091 "
OWNER'S NANU I APPLICATION SUR DATE
RIEN GROUP '=1:880_ S. .73H ST 03/16'/2001
SANITARY NO, - CON'I'ROL NO!
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" . (408) 27572263 .
14 O O ARCHITECT/ENGINEER:' � _ _ Blll LNG PERMIT INFO
dk m C BLDG PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION
Z oi1hcrebr rmal 1: hccnad andeimskmn+nl Chapter 9 tcummenems - - - - Job Description
-
FyCLJ with Sc Nan Ylgllpnf Divisionn3of the Business and l'rple,sinns CaJ<.:mA my license
is Lice
full farce nnJ eBcct.
o Date c-4S, o to ).,I in tLyD TEMP POWER POLE.
3,rte Dale_'}=(.6— /- Cnmmmnr .
< ARCHITECT'S DECLARATION _
1 nndetn,and my plans,ball be umJ un public reenN,
pu�fY
uddl C p Liceri 11rnfcssiunvl
E OWN,R-IIt111.D1i12 UIiCLARA'fION' x
133at, I hocox,hy am.that I wain exempt;;1;r"'he Courtrai Liccuia,Laos for the
Poll t,g r n (Section 7031.5.Business and ProodfiNsourno,Coade Any city r oulny
Which rest. crriI I Ih p I I'1 ooruem,tinya uurc
3 pdr or t L req ,1 pphcam f f u h peal,G fl g d t t mem -
matsiv is Iver,colptarstuartt d p . n l r c tail c wfna,Cad9 Sq. Ft. Floor Area' Valuation
or that ee is exehSe.onrion and the basis
Bus .. IionfAxoeCnJel _
of Sec he is exempt herefmm and,ore aphis for the allege)exemption.Any violminn $0 -
afieva Section 7031.5 by anyapplicantullon,Spennit suM1jttts the upplieunno acivil pemalry _
. •nrnot m.m man Eve napared nouam lasnln. � APN-Number Occupancy Type
01. n.ac,of the pmpenRof my employee.s with wngev'shei...leem,perea er, 342F. 10
will In the work,sort,he svumure is not inn'ndcd or offered for tale(Se,7044,
Business and Processions Ctrdi The Commuter's Llccnm Law dues ant apply to an Required Inspections
n;w r of prnpeny Who Ni improves thenmn,and who Ane,such Is k'bim,ell' - - -
r through his own employees,pmvided that Such mllrmvmnents one not mtionded ar 304 — ROUGH ELECT R I CAL
Rcred lot sale.If,however the building or improvement is sold within one year of - '
mnpledmn,the ownealmnder will have the burden of proving that lie did not build nor '501 . — FINAL ELECTRICAL_ ENERGY -
alp !.Pula- f 1 ) ., 505 — FINAL ELECTRICAL_
.Ola tilde p ptyal rachisiVifly Lurnacting With licensed ructractimsm
con'wcl the pi t(S 70,14 Burviress and Prificesions C al )The C sumo's -
I.iee+,c Law days urn apply,o an owner ort pmi Who bu Ids for tm,ei vee,lumun, _
and who.ccmmcrs li,r such prnje.s with a c.ntmcons)licensed pursuant m the
Contacud,License Law.
O1 am exempt under Se,. ,B At P C tax'his.,.a '
Uwncr Data .
WORKER'S COMPENSATION DECLARATION -
Ihe'eby arfien under Penalty of Pei one of the following declaration;: r
❑ 1 nave and will n.amain . Cc.tificnm of Consetn to sclrinenm for Wnrkc,'s _
C'ompenestinn, as pmvidcd for by Section 37W of the Labur Codon.-for the -
To..ri car the wni far which dr,per itis I,WWi v, _ 4 ,
❑I have and will maintain Witter',Com ns n s
pe mi n In umnce,as required by Seninn
N
1 the"I Code,cr the Insurance c of the work 'or vii re
1 n h this .alit is
P K '
.hfy WnrkctsC mpcnsatinn lmm�mcc rncicr nnrl Policy nutnMr arc: -
54{%4•t ttAln [tPi Nn.: Sof—0c,
CEIG IIICATION OF EXEMPTION FROM WORKERS'
'COMPENSATION INSURANCE
- (Di'scetion need nal he,vmplcted if the permit is lira ene handed dnllnls a
(510111 ar les..)
1 ttnify Ina,in the pprforach of the work for whi,h Ibis Penal is issued,I s
shall net employ any person in any container w as A become subject to the Workers" -
Cninpemminn Laws nfCnlifnrntu,Late
Applicant ..
NOTICE TO APPLICANT:If,after making his Ccnificme of Exemption,you should
Q Oaecaur object ,,the Woi Cuan,ors:niun provisionalo the Labour Cote,you in,, '
Wnhwim comply with such prop,siun,or tai,permit shall be Aecmnl revoked.
Ta. CONSere CTIONi,."ans LENDING AGENCY_ " -
' I hereby Which that there is csorted inn lending agency for the perfomrmce - -
�,
Leader
I N for which this permit Is issue)(See.J(MJ7,Clv.C.) -
On'A Lender's Add
. U,z Ltter',AJdmsee . ... ..
Q1 cenify that I have rend this applicmunl and state that the above ichei atian is
g, E. correct.I agree'.cutnply with all city and eouny anlirrance,and ,;it,laws r ing
U to building octet...inn,vndereby ahiae ho repeciiratives ofhis city as emer.,,a ' -
} W the ehaveanentioneJ pmpmy for itrgactin 0 pnpn„ex.
(We)agreetoo vice,indemnify and keep hurnmee,the City(of Cupeninn against
N liabilities,judgtnenrs,costs and expenses which may in any way accrue against said `
C,7Pul
gacnee of the grantingofthis pe nm 1.UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' Date E oU.nT1ANS p�,,..� Issued bf Appheanvenmmemr F a.Q DateRe-roofs HAlARDOUSMAr:RI DISCLOIUIOIEtheafflicanorfuturehuildia,wri,para,mmortHandlenaay.danStt'oterial 'Type ofR
m Aclite!by the Cupeninn Municipal Cada Chapter 9.12,and the Hii and Stfcl,
Calc,Scion 255320)l'- - _
: ore> • oleo - , All X fs shall be,inspected•prior to any roofing material being installed:
Will the applicant on mare huilti ng cecupant use equipment nr devices which If a roof is installed without first an obtaininI,g inspection, I'a ree.to remove
ChunChunhanNous air contaminants as defined by the lf:ry Arca Atr.puality Munagemm . p �'
Di,nfato reS El N;, ,. all new materials for inspection. Applicant understands.and will comply with
all non-.point source regulations.
I Imve read,he hummmus materials requirements under Chapter 6.95 of the _ o
Cori Herlih k SaLl,Coah.Section,2550.5,25533.,,it 25534.1 understanUmat _
if Ite building does not currently have a tear ,that it is my mN,msihility to notify the
r,jc.ocfp.I of the rcyuiremens which muit he met pHoser t.his...ce of a Certificate at '
Y.�[p,�`_. Signature of Applicant' Date
o�'tt'odd.Taget't`*- - - Date�t • -
All roof coverings to be Class"B',',or better
OFFICE.