05030232 CITY OF CUPERTINOri^s�- .z ".3 '• ":� ."
BUILDING DIVISION PERMIT "CONTRACTOR-rINbFFORMAT10N_M
BUILDING ADDRESS: ACME & SONS SANITATION/ELE PERMIT
OWNER'S NAME: - PERMIT ISSUE DATE
ONE: SANITARY KCr t6bIROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
to, LICENSED CONTRACTOR'S DECLARATION Job Description
�
oilC ith 1 hemby affirm shat I an licensed under provisions of Chapter 9(commencing p
IiW wSeeuon7UMB)of DivisioBusiness;3 ofom Business;and Profen iuru Code,avu
nd my licenF iicenfaoeandeR�12 ttn,, Slll O� ,TEMP POWER POLE n
y License Class Lic.A
n—n Date Cumractur AI G7 Som E ce r rn
££ ARCHITECTS DECLARATION
W u I understand my plans shall W end as public records
3 u. Liceoed Profoxam al
OWNER-BUILDER DECLARATION
0 0 I Wreby.(Scc that 1 1. exempt front Pr Caonmors License law far IW
m a O following mason.Permian 70I LA Business and Profwiuu Code:Any city or county
which requires a permit re eonevueL ager,improve,demolish, fi repair any souctum
Prionn its is sed pen umot to ms thevisio s of foe Contraatch ctors
m canoe Law atammcm - ,
U4 (cot he is(commencing
it pSection 7 the provisions of the a Business
and
Prue inumC odmr9 Sq. F[. Floor Area �� �c �f //f)ValUat On
ass• (commencing with Seniors 7")of Division Sof @c Busirru end Prrfcasioe Code)or
U, $ Ibat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant m a civil Penalty of 3 yQ3etp p Occupancy Type
not mom than five hundred dollars($5(10).
0 I,u owner of the propeny,me my cmploycet with wage u their sole compensation,
will do the worse,and the someone is not in ended or offered for sok(Sem.7W.Buinw
and Professions Code:The Conuacmh License law doe not apply in an owner of Required Inspections
property who builds or improves Nidi n,and who doessuch work himselfor through his
own employee,provided that such improvemcnu tic not intended or pffered forsake.If.
havever,the building or improvement is sold within one year of completion,the owner-
builder will have the human of proving this he did not build or improve for purpose of
sale.).
0 h as owner of da pmpeny,am exclusively contracting with licensed conoanon to
cemwm the pmjem(Sec.]One,Boinw and Professions Cade:)The Contractors Li-
cense law docs not apply u,an owner of propny who Wilds or improve themon,and.
who contracts for such projects with a eomrumr(s)licensed pursuant in the Conuaetors
License law.
0 1 am exempt under Sec. B k P C for this moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations:
I have and will maintain a Certificate of Consent in self-imum for WoQuesCompere-
sation,as provided for by Section 3]00 of Ne labor Code,for the performance of the
work for which this permit is iuucd.
0 I have and will maintain Worker's Compensation Insurance,o required by Section
31
00 of the labor Cade,for the performance of Ne work for which this permit is issued.
My Workers ontpanodom In...artier end Policy number are:
Cartier. o Policy No.0 1_n__ S(t ole
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he complemd Uthe permit is fortune hundred dollars($I00)
nr les.)
I certify that in the performance of the work for which this permit is issued.I shall nut
employ any person in any mannereco as in Wcame subject to the Workeri Comprasation
taws of Cakifornia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifcam of Exemption,you should
become subject in the Worker's Compensation provisions of lW labor Code,you must
.J O forthwith comply with such provisions or this permit shall W deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
Fw^ I hereby affirm Na them is a convection lending agency for thc Performance of
C A the week for which this permit is issued(Sec.3fy91,Co.C.)
Leaders Nater
=Z Lender's os
Addrs
V O 1 certify that I have read this application and sum that the above information is
(y ^
comet.1 agree to comply with all city and county ordinances and sum laws relating in
C) CEJ^ building convection,and hereby amharim mpmsenmims of this city to enter upon the
r � aWvO mentioned property for inspection purposes.
(~ G (We)ague to save,indemnify and kap harmless the City of Cupertino against
rA liabilities.pigments.eom and expo.which may in any way accme against said City
C)Z in consequence of the graining of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
I=
REGULATIO"� r
n a--_\ Q • 3 610 S Re-roofs
Signature of APPiicanUComm(cor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hvamous material
u defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Satiny
cmk.Section zss32
(11
1
]
0ypAll roofs shall be inspected prior to any roofing material being
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it ha ardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
siren //
D Yes No
I have end dm hvadawsma¢rials mquimmenu under Clupmr 6.95 of dm Califor
niceHelthhSafctyCode.Sttvmu25505.23533u 25534,lunderstar irthe Wilding
d it ennead,haw•mount dun is u my resppmibilitY to mory the aaupam of IW
u mcntswhich m Wmetpoorantanceaa cnifiemofOccupancy SignatureofApplicant Date
1l1'g0a't b• 3 E2 I�� All roof coverings to be Class"B"or better
Owner or aahorivcd agent Dam
Community Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408) 777-3228
CITY 0, Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT #
10-�,2v � - �� 0.�� SCJ , OaO30L3
OWNER'S NAME: We• d ne 1 (o^c Jc PHONE #
GENERAL CONTRACTOR Pxo!f Sohl ec , c, FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # .
Cabinets &Millwork
Cement Finishing
1✓ Electrical N ME Sor Srnh 1 0 1-)
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
TEMP POWER 3,C�CITY OF
z3Z_
'ICUPEkTlNO PERMIT APPLICATION FORM
APN
Building Address:
103z0 rhe avt2C), -D
Owner's Name: TC, Phone #:
� 25 -5
Contractor: Phone: License #:
N(f-Aq S0 ,j �.yOy-' a? 2L .5W00
Contact: Phone: Cupertino Business License#:
uilding Permit Info:
Elect d/
Job Description:
i-evv\
Residential Commercial ❑
Cost of Project: o
Qty. if
Applicable Fee ID Fee Description Fee Group
( BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
V
/ 0 1�7
j