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CITY OF CUPERTINO
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INFURMA"f�IO:
BUILDING DIVISION PERMIT
C®N1�RACs„U,R
BUILDING ADDRESS:
ACME & SONS SANITATION/EL
PERMIT NO.
TRI 05040171
E M :
PERMITL95UEDATE
NE:
(409499 2263
SANITARY OL NO.
1
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
O
LICENSED CONTRACTOR'S DECLARATION
lois Description
1 hereby affirm that 1 am licensed under provide. of Chapter 9 (cnmmetln{
P
with Section 70Xp car Dividon Sof the Bus nes, sed Prakuiuns Conn. and my Time. u
In full react and affee
Lima wCis tie.« o�
TEMP POWER
Deu Conusam
ARCHITECTS DECLARATION
I understand my plans aWll W used as public words
Licensed Prof ..kraal
OWNER -BUILDER DECLARATION
I hereby affirm NB I am exempt from the Cnntr.ro's License Law for IW
following reason. (Section IID 1.5, Business and Profcalons Cade: Any City of county
which mquiras a Permit In ennuaat, altar. Were”. demnluh, car mpair any enuelum
Tudor in its issuance, also requires the applicant for such permit to file a signed armament
Sq. Ft. Floor Area
Valuatio
Net he is licensed pursuant m the provistou of the Comracmr'+ Liceme Law (Chapter 9
(comm .in{ with Section 7000) MDivision 3 of Ne BuTlrem iuni Premed.. Cole) o
That he Ie exempt therefrom and the basis for the alleged exemption. Any violmlon of
,�p ,7�a, t�
319Y IPl?e! 0 0
.ecu enc e
Occupancy TYp
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of
not more than faro hundred doll., ($500}
❑ I, As owner orHke prepeny, Army employee, with wages. their sale compensation,
Required Inspections
will do The work, and me atructurtlaanUntended moRered for .1.(SmJOa, B.I.
Nd Professions Cade: The Contommes Liven¢ Law does net apply u an owner of
9 P
properly who builds or improves thereon, and who doe+mch work htm.if or through his
awn employees, provided mel such Improvements arc not hummed moQered ferule IL
haws.,, the Wilding ar improwm el Is mid within oro ye. of completion. The owners
Wilder will have The Waden of Proving that W did not Wild or Improve for purpose of
❑ 1, a owner of me patient, am excluiwly contracting with licensed contractors N
construct the pmjecl (See. 7061. Business and Prefesaialn Cade:) The Contncmrs LL
«n. law does am apply m an owner of property who Wilds of Improves Hereon. and,
who comrsets fm such projects with a tonuaelor(s) licensed par u nt m tits Contractor's
Lken. Law.
❑ I am exempt under Sec. . B A P C for this mann
Dau
WORKER'S COMPENSATION DECLARATION
00W.,
1 hereby affirm under penalty of pedury aro of tau following declarstlom:
have end will mdnuin a CtrdOesu of Consul loaf -Insure far W.keh Competeon.
u provided Corby Section 3700 of the Labor Code, for the performance of the
work for which Nb P.mit I. issued.
❑ 1 have and will maintain Worker's Computation Insurance, a required by Section
3700 of the IaacrCade. far the performance of the wart far which This permit la luued.
My Worker's Itnl+unoce envier and Policy number am:
x �CCohmIpenation
CimidoPrAlw- fLIN� Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thu section ted not W comple"If the Tuermll h Carom hundred dollar (SIM)
or Ids.)
I unify Not In the performance of IW work for which this Permit Is issued, I eh ll not
employ any person in any manner. a It Wmllle mb*l to IW Workers' L'ompensatim
Laws of California. Deu
Applicant
NOTICE TO APPLICANT: If. after making this Cer ificate of Exemption, you shoed
become subject the Worker, Compensation provisions of the LAW, Code, you must
faMwith comply with such prmisiom or NB Permit Nall W deemed mvaked.
LENDING AGENCY
1 hereby affirm that there its construction lending agency for ted Mrfurnmom of
ted work for which this permit B Issued (Sec. 3097. Civ. C.)
Lendef, Narm
Ludees Address
I certify that I haw reed this application and stake that the slow Information la
coram I agme to comply with all city and county ordinances and sum laws relating m
Wining construction. and bereby sumodce representatives of India city to CAW upon me
aWw.mentiolled property, for inspection puHlosea
(We) agree to an, indemnify and burp, h+nalea the City of Cupertino &&,Intl
Ilabillties,Jud&menu.wm ad expenses which may In my way mcao against said City
I comequcnee of a &rAn of this it.
APPLICANT UN R ANDS O ILL COMPLY WITH ALL No
Issued by: Date
.-ROURCERE UL 0 .
Re -roofs -.
'-
Type of Roof
NN5AZ'7
51{nwar of Applimu Caufactrr Dau
HAZARDOUSMATERIALSDISCLOSURE
Will the appllunt or fol. Wilding oceupanl arum m handle hatardous materiel
As dcflned by tam Cupenlno Municipal Code, Chapter 9.13. and the Health and Safety
ode, Section 25532my?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applic&m or future building oc<upam tea cyulpmem or dcvkce which
Ali hazardous air comaminam+a dcOned by the Bay Area Air Quality Management
all new materials for Inspection.
.District?
❑Yee �o
I have reed the WvaMnumauda4 requirements underCNpkerA.93 ofthe Glifan
nix HCAhh&SdclYC 'ons 13303.13337an 15334.1 undenund this iftha Wildin&
dons not currently ha m e t, that It is m nsibllhy to notify IW rccup.t of Ne
nuwhichm Ipdarm aft CcrtiOcake of am y.
Signature of Applicant Date
_¢y�mm
z7a
All roof coverings to be Class "B" or better
owner. ndred. eat take
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
OCF Fax(408) 777-3333
�UPERTINO
Building Department
•
JOB ADDRESS:
I C( 'A�Ax--
PERMIT #
o�-OgoI
OWNER'S NAME: t(- N 6
PHONE yob 838 - O 2m o
GENERAL CONTRACTOR: /9--rco/u<-, n/G
FAX# ( 36Z—L(G?i
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor Signature
j -d -z
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
. ICME, f 5A-24
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
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Date
(F
�CI OF
CUPEIZTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
oko
APN # 37� 37 e,> (;e
Date: 2 7/0
Building Address:
EPERMITFEE
'Elect. Permit Issuance
ELECTRICAL
Owner's Name:
My- n/ G Do
P ne #:
yb£i X38 -oZQo .
Contractor: Phone:
License #:
AC,IL44& SAt4 TAe-
Contact: Pho :
Cupertino Business License #:
Mld\i * .` 7-,A X� 65b 6
Building Permit Info:
Elect
Job D scription:
Residential Commercial ❑
Cost of Project:
ZSR
J�
Qty. if
Anolicable Fee ID
Fee Descrintion
Fee GrouD
BTEMP
Temporary Power
ELECTRICAL
EPERMITFEE
'Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
`2-