02070164 CITY OF CUPERACTOR`INFORMATION: ;`.
BUILDING DIVISIONSION PERMIT .:CUNT
BUILDING ADDRESS:
10121 IMPERIAL AV ACME & SONS SANITATION/ELE TIi'62070164
tIoffWf MICHAEL 3408 HILLCAP AVE APPLICAAGI1$SjL Eq,ATE.,002
PHONE: U
(408) 295-2263 SANITARY NO.. CONTROL NO.
s Z ARCHITECI7ENGINEER:
O O BUILDING PEMIIT INFO
BLDG ELECT PLUMB MECH
I I EI L."7 II
5H z LICENSED CONTRACTOR'S DECLARATION
',Z-O the by aRms that l am licensed under provisions of Chapter 9(commexing TEMP POWER TAYLES�YFtiW TOWNHOMES
mite with 5ccuon]]]0J0)elOivision lofdhc Busines9aAd Pmfcssions Code.and my license
',Y�� is in full(prQe vntleReet_ Y/ � rI t � V
O U Lice Li
Contract 3 '/A
cmc•ARCHITECT'S RATION
O
on, 1 undensond my plans shall M used es ublic rcmrds
p o Licensed Professional
OWNER-BUILDER DECLARATION
In 1 hereby.(Beat that 1 oat exempt Business
from she Convenor's License law for the
t?<
following xenon.(Section 7031.5:Busines and Pmfeuio li Code:Any easy s county $1000
Ea F O which rt v rmit re construct,aper,improve,demolish,ore A lir my asrvaum
5 3$ IAlihud imi s requires me applicantumothe Cop permitoice signed immanent, ._ _ _ _ .... „_ _ _ _
9 Pe
no us issuance,e _ .... ..........
praumkjoth)ofDsiomn3ofthnuacmrsLiMProfew(Chapter9 3gqyy1F1.Q7�c.@t@a•, Valuation
(commencing eat n70fi0nd the basinor t she Buedeu AM Professions Any
Code) 1,,.1�\ ir.;__t!"j7 v,,j i• a-_3s t,rr:,-114, ; �; `t '
Or that he ii 31.3 b thercfmib end the put
for the subjects
alleged exemption..Any l genion
-of Secsion'/IK.0fiev hundred
dollars
subjass she vpplicvmmecivil penalty' 3APN MSI
Idf not mort sfien five hundred dollars(iS00), 10 lswul Y[ua j '+- � � Occupancy Typo
°I:as owner of the property,or my employees with wages us their sole compensation, 304 - ROUGH ELECTRI AL
will sdo the work:acid toe grvcmre is not intenterr offered for safe(See.7614.- 1
Business sad Professions Code:The Conmaaus License Law does not apply in an Required Insp'ectioiis - '-
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements arc not intended or
_
offeredfoml If however.theb Idle _._ .
8 P f prove sold he didoneyear of
complus,on,the owner-W Idem wdl hamthe burden o(proving that he did nos Wild or
improve for purpose a(sele.). �
°P as awnecof the pmpeny,oat exclusively d Pronmg with bee s d contractors I FIN
vonsimn me proles IS 7044 Business vntl Profess nm Cotl )Th C ntiutor s a X04 if
Life
Law docs nm apply to an owner of progeny who W dds onmpmves thereon,
_.vntl-who.consrnns.for.such pro
nt-with a conouca"lq licensed.pursuand.m she
..... _ _
'• = Cantrvnoh License L°w'.i:.I _ —_ -. ___ ______ _ _ __...�__._.._..__.._______.—_.__.__________
a: ❑1 em exempt unddm Sec,' P.0(onhis reason
00
Owner - "Dem Pr -
<_,`.t?" WORKER_gCOMPENSATONDECLARATION BUILDING
S
I hertby aRmm under penvhy of perjury one of she following dechmtions:
:1CC d ° 1 hi4said'wi11 maintain s&e ificnd'of Coned to'self-insure for Workeh
Cmagxruni... ...provided for by Section 3700 of he IaWm Code. for the
_ 'peRonoence of the work for which this permit is issued.
°1 have o;d•will maintain WoAer's Compo Sato 1 sumnce gs reeuimd by Secsian
- 3700 oft he Labor'Code,for the performance of the'wurk'far which this pemtiCis
issued:My Wo ker's Compensauma Inadm!'carrier nJ Policy Aumticr see_
r C (•r - .Poli ' I U10<c/`S �'i.a, 1' '.:1•,•p 1 ;:ai- v .._ .- ii.t ,s. ._
1:r y 4 CERTFI
.+:. . .rn.. .
rr'.COMPENSATION INSURANCE
',i.,,_. .. ........ ..... . ........
I:F (Th s senioti rated not be completed if - ,
(5100)o less.) p perm ns for ore hundred dollars '1.'. t ':I ;"\ ��}p + : . T..p,
,hall
l u 1 emfyy mum theperformonce,of)h s k for wit ch sits.permit is issued.I - ; a c ,..p.shell I mploy any,pe m ony'mann'r m os to bimme subject io the Workeri -�• k I'
rope,etim,Lew,of CaIip mio:Date'
App1 t ... -.. ...
NOTICE TO APPLICANT If oft ok n this Cen f to ar Exeshould - — - - _
boost belt to the WorkenC g Piton . st
,� j pe ,l n p o ons of the Lab r Code you- t
O Q f6nh tit comply with su[h Provisions or the pe t hall bed tl revoked.
-- --
Fy-� ;fONSTRUQ'ION,LENDING AGENCY
ai ".he by Rnn that there u e conssmn o lentl gg e enc for she rfo'rmena p
W ofi
he okfr itch this hall d(S c3097 CrvgC)y p` t'
5.Z Lender s N me
nJer Add ass' - - .. •.. ._-.__ _ _... .__
U:0
I seemly diet I have mad this application d me that the above information is i
(�'F.U 10 buil 1 agree to comply with ell city toed county ordinenas and c t lows enter.,a Q.:V to b.v1-snnswciio6peny And foimpoudimpm iesemvtive- this city toenmmupan
'ow the above.)ij ixm'6.Anp:indemifyAdikephlrtals.
(�..a Ga' (We)egmesorove;indemnifyend keephemay in rite way of Cuperiino ageimd
ir-fp liebilitics,judgments,costs antl epcnus which may in any way ettme Against said
U 7�. City m conugocnce of she ".11 b' perms '-`
sPPLIQA.NT�y�n,D�'AER T DS. D MPLY W LTH AL OriTry Ni i'' /Y/
UR < &111 �/ /N l Issued by: Date �/
gn Pelican✓con or .' Re-roofs
t HAZARDOUS MATERIALS DISCLOSURE �'
Will the applicant m future building occ pent store or handle hoiallo mete it - . Type of Roof
As defined by the Cupertno Mi <peli Code Chapter 9.12.a d the Health and Se(ry ' -
Code °Yes Sudan 2533207/ tr` o 'f I y u,1 1 q,., s,.l Is' i. ,-•� t St .. '',i) .,r„
_..All roofs shall be inspected pnor_to.any roofing.matenal.being
'- eubuilding
installed.,led..W,IImeeppanfmrc WIdingoccupe see equipment
mit harWuArcnum non es definedb theBy AreeAr Quality MAnegemenl. If a roof is 2nstalled'wrtfiout first obtainingan'ins ectiiri Ia'agree'to remove ve.
�... .._.._.
"'"°' - - •_ . _ •all new materials for inspection_Applicant understands and will.comply with-, _
°Yet k om 'f, all non-point source regulations .
I ha e.rcod the'InizW.us maicdnils quiremems midor Chapter 6.95:of the
califumu HA.Idb&'Safety Code 101p
25end 25534.1 understand that
if me buildin d of currently h" a icnent,t .i"i"s my responsibility to notify themac at of J¢rcqulreritenu t - to luuance (e Ce-'Ocese of
Occupan r -
Signature of Applicant _.
- Date
coveringsmed:ed?gent All roof coverings to be Class B be't
or
ar.
... E .