04100122 CITY OF CUPERTINO
BUILDING DIVISION PTRMIT CONTRACTOR INFORMATION:,
BUILDING ADDRESS: ACME & SONS SANITATION ELE 'lh''FkFN04100122
308 A RAINBOW DR
OWNER'S NAME: PERMIT ISSUE DATE
CENTEX 3408 HILLCAP AVE 10/18/2004
41 HONE: SANITARY NO. CONTROL NO.
(408) 295-2263
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
AJOp LICENSED CONTRACTOR'S DECLARATION ]Ob Description
WI berth affirm that I am lice 'unnk visions of Chapter Y Immmcncing p
with Sc ) fDlvision3of Nc Bust dProfcssinm C.dC,andmy beemseis
o mmur Jef(Ec TEMP POWER
p Z Licc Clms f, U LC,N �II/fes
a:f,0 Data Connvcm
//''�� ARCHITEC u5 DE ION
f l9ndcr nJ �✓ashes]] dupuMic records
1 \�� .JdL-r
�p L cesinnal
OWNER-BUILDER DECLARATION
0 0 I masa affirm that 1. exempt from Nc Contractor's e:An,c Low for the
aO following reason. acoutt Tonstr Business and improve,
eipna Cnoc:Any tinyfircounty
x which requires a permit re ammweL alteh ire prove,h Permfi,fire a sig any sruaum $500
Flathat heor it)sliensedpursuanttoda the pmvsiitnsofant for sucContrarmltmiense signedstatement
that he is licensed pursusnup theprovisinns of the Contractor's License Law(Chapmr9 Sq.Ft. Floor Area Valuation
W
�� 0.1 he inciag tdi.ofters and nl Division r fr N11C,td exe and on.Any=
Co to
y�$ Nat he is exempt Ncmfrom and the basis for Ne alleged exemption.Any vinlmipn of
Section 7031.5 by any applicant for a pmmlt subjects We applicant o a civil Penalty of
not more Nan five hundmd dollars(5500). Occupancy Type
I,as owner of th,property,or my employees with wages u their sole compensation,
will do the work,and be structure is not intended or offered for cele(Sec.70,14,Biannes
and Professons Code:The Contractors License Law does not apply to an owner of Required Inspections
Property who builds or improves Nereon,and who does such work bimxlfar through his
own employees,provided Nu such improvements are not intended or offered formic.If,
however,the building or improvement is said within one year of completion.she owner-
Wilder will have One burden of proving Nm he did not buil)or improve for purpose of Cp��
sale.).
❑1.m owner of et prnpcny,.B exclusively and contracting with licensed contactors i-
cemwa the project(Sec.o in wner of
and rty who Wilds
Code:?The Contxmr's fid
who few docs not apply to an with
a of property who sed a or improves Neman,and
who seLacu for such pmjecu wiN acontranor(s)IicenxJ pursuant to nM Conva<tor's
License Law.
❑I am exempt under Sec. ,B&PC for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of the following declarations:
1 havc and will maintain a Certificate of Conscnt to self-insum for Worker's Crones—
�"- ¢lion,u provided for by Section 37M of Ne Labor Code.for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by SCcton
37W of be Labor Code,for the performance of the work for which Nis permit is issued.
Morker`'y'Compensal__io/n Insumnce Cartier and Policy number a
C er. Cfi✓'yl Polil tr t �G�
CERTIFICATE OF E%EMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M co ninhucJ if the permit is formic hundmd Jnllars(SI W)
less I
I certify Nu in the perfimnance of the work for whish this permit is issued.I shall nm
employ any person in any manner an 0 to become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cent l icue of Exemption,you should
WCome subject to the Worker's Compensation previsions of the Labor Code,you mus
.J 0 forthwith comply with such provisions or this perm it shall M deemed mvnked.
ZN CONSTRUCTION LENDING AG ENCY -
.F I hereby sRrm that Nem is a construction lending agency for the performance of
Qi ti
the work fur which this pens it is issued(Sec.3(07,Civ.C.)
W Lerner'a Name
z Lender's Address
J 0 1 anify that 1 have read this application and stse that the athi information is
Ot" Correct.I agree to comply with all city and county on inanees and state laws relating to
V building construction,and hereby aothome representatives of Nis city to enter upon the
G above (We) gmentioned to ertymvc for inspection a keep ha
(We)agree to save,indemnify end kap harmless the City of Cupeninn against
F N lioblliticsfugmenks.costs and expenses which may in anyway accrue againaLmid City
V Z in Conxquenicer, Negrano orchis permit I[/
APPLI ANT D DS ND WILL COMPLY WITH ALL ON-POINT Issued by: Date
RE I
O ( D" Re-roofs
S mo pplicara Contactor ax
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W INC applicant or future building occupant Store or handle hamNnts memnal
as defined by Nc Cupertino Mu cipat Code,Chapter 9.12,and the Health and Safety
AdKC.dC,Sc❑ctfon zss3xa)? All roofs shall be inspected prior to any roofing material being installed.
cs
Will the applicant or f terc at
occupant use cyuipment or Jcvi<m which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air cnntaminanL`as defined by the Bay Arca Air Quality Management all new materials for inspection.
District? ''t*,g1//J,,
Ycs
1 havc read Ne haraNuus matari"s myuircmcnu unnkr Chapter 6.95 of Nc Califor-
niaH.INSSafety Cndc,Sections25A)5.25533and25534.1undersand Nsif Ne Wilding
Jhes not Indy a t n t it is my respom mBIy m tiny t oacup of Nc
re
w i u prior to issuance of a Cenif of C /
(U G�1 Signature of Applicant Date
Own mixed, ant Date All roof coverings to be Class "B"or better
Community Development
1 ; _ 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
� CITY OF Fax(408)777-3333
UPEI�TINO
Building De artment
JOB ADDUSS: pE
U w
OWNER'S NAME: PHONE # c o S_
GENERAL CONTRACTOR:
AN
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #inet
Cabs &Millwork
Cement Finishing
Electrical
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
I
Owner/Contractor Signature Date
CITY OF CUPERTINO
TEMP POWER o ( c5v 2 2
ICITY OF-
CUPEkTINO PERMIT APPLICATION FORM.
APN# � / ( G Date: �
Building Address: ✓1
U 9j ai Vl ba w ))r-
Owner's Name: Phone #:
C ntractor: Phone: License #:
Ahl � k 564S 5�,,, afr�ti LKCY 29s" -,7)-
Contac�tt Phone: Cupertino Business License#:
oe+T tr ),t er 4'oY 205 - 301
Building Permit Info:
Elect 1k, wQ
Job Description:
Residential Commercial ❑
Cost of Pr ' ct:
Y• .f
cab Fee ID Fee Description Fee Group
,BTEMP Temporary Power ELECTRICAL
EPERMITFEE 'Elect. Permit Issuance -ELECTRICAL
BUSLIC Business License BUILDING
/27 ��