05040026 (2) CITY OF CUPERTINO
BUILDING DIVISION
PERMIT NTRACTR INFQ,RMATIQIV
BUILDING ADDRESS: PERMIT N0.
ACME & SONS SANITATION/ELE TRI 05040026
OWNER'S NAME: PERMIT ISSUE DATE
.ONE: SANITARY n ndkYROL NO.
ARCHIL fENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
I Mmby affirm that 1 am licensed under provisions of Chapkr m
9(eomancing
with Sector,701D)of Division 3 of the Business and Professium Code.and my license is
in full fora and ��///OD
^jz D ver, I �� Li trgasmr TEMP POWER POLE
ARCHTIECI'S DECLARATION
'y9 I understand my plane shall he used Is public reearde
Licensed Professions
OWNER-BUILDER DECLARATION
I I hereby affirm that 1 am exempt fmm the Contractions License Law far the
AO following m (S
reason.(Salon 71131.5,Business and Profaasim
ons Code:My city county
MI E! which requires a permit to conatsu0.alar,Improve.demolish.Or mrsur any structure
H priori in issue=,also requires the applicant for such permit to file a signed sutemcnt
ggggaFF< tutheisllanmdpunuentin the pmvisionadthe Comrxur'sU..Law(Chips,9 Sq.Ft. Floor Area Valuation
bs (commencing with Section 70E0)of Division 3 of the Business and Profession Cody)ser
that In Ie exempt temeGom and the basis for the alleged exemption.Any violation of
Section 7031.5 by atry applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy iType
nut mare dun five hundred dollars(S5001,
❑I,as owner ofthe Property,army employers with wages u their sok compensation,
will do the wort.and thestruture is not Intended mattered Imaale(Sec.7044.Budeace6940015 . 00 Required Inspections
cepa Profusions Code:The Coad aeto's L umme Law doe sol apply in an awns of q P
property who builds or i m proves therton,cepa who dou such work himself ar through his
own employees,provided that ouch Improvements w notimmuded aroff Wfor aceta It,
however,the Wilding or Improvement is sold within oar year of completion.the owner.
Wilder will have W burden of proving that N did not Wim Or Improve far purpose of \
ole,).
❑I,as owner of Ne Seely,,Business uand canumning with:)Theed antracun u Jv
comwm the project pply 0 an wnrofend Rowhoam Code:)The Conmcur's I.I.
cense Law coca not apply m an owner of property who builds or impasse Centro.rod,
who contracts for such projects wIN a cantrxmrO)Ilanse0 punuam in the Contractors
Lieema law.
❑1 em umnpt undo Sec. .B k P C for Nis won
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby 4111m,under pcmlty,of pedury one of she following declarations:
1 haw and will maintain a Certificate ofComent m selfArsum for WorsensCompen-
sation,u provideA for by Sectimn 37011 of the labor Code,far Nn perfonmance Of to
work for which this permit m issued.
BTM1sve and will maintain Worker's Compensation Immense,u required by Section
3700 of the Labor Code.for the Performance of the wart for which this permit is issued
My Worker's Cpompenu0on Insurance carrier and Policy number am: SILO
Cartier. '6 /7ppLLCL/A��Poliry No.:
CE FI TEOF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
Missectan road not hccampleted lines permit ie fmaahundred enllan(SIM) .
or sen.)
I certify Nat in On,port...of to wort far which this Permit is issued.l Nall nes _
employ any person In any consumer an as m become subject to to Worked Compconfian
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making Cu Certificate of Exemption,you should
became subject in the Wake's Compensation provisions of the Labor Cade.you most
0 fOMwith amply with such provkinns or Nu Permit shall be deemed rewked.
Z�5 CONSTRUCTION LENDING AGENCY
(~ I hereby affirm that Nee is a construction lending agency far the mrfmmana of
CYa rte work far which this permit is issued(Sec.3097.Civ.C.)
W� Lender's Name
Z Lender'.Address
C)Q 1 certify Cat I have mad this application and cum that the above infonmatmn la
lL^ army 1 agree in empty with all city and aunty ordinances and sum bw relating to
C SV' building construction,and hemby authodre nprChuuliM of this city m enter upon the
W ahavo-mcmioned Property for inspection Purposes.
(We)agree to save,indemnify and keep hmmkss the City of Cupertino ailing
y liabilidinjudgmenu,cans andexpnstes which may In any way acre against said City
V Z to consequence of the granting of Ng permit
IMFE UNDERSTANDS AND WILL COMPLY WITH AL O�OIM' Issued by: Date
f�h/JJ({g/a !� Re-roofs
Si tame ol'Appit iXonuecur Date
HAZARDOUS MATERIALS DISCLOSU Type of Roof
WIII the applicant or future building recupantstom or handle hosrdom material
as de0ned by the Cupertino Municipal Code,Chapter 9.11.and the Health and Safety
cads,ScNrn 15531(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yca [3 No
WIII the applicant or fuum building Occupant use equipment car devisor which If a roof is installed without first obtaining an inspection,I agree to remove
it hanninus air conlemin us as declined by the Bay Area Air Quality Management all new materials for inspection.
sulcG
❑Yes 16N.
I hm read the hassmmu mammies requirements under Chapter 6,95 of the Califon. '
MAHerl Safety Code,Sections 15505.15533 aW 35534.1 undarnnd dig tribe building
doe y hew a moans,that It u my msprnsibllity m bully the arupanl of the
roqu n ice mu br uInnocent.certificate OfOc a. Signature of Applicant Date '
0%o rte car amhmri oar a I ,m.14 All roof coverings to be Class"B"or better
r or authmixedegbir,
Community Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408)777-3228
CI OF Fax(408)777-3333
�UPEkTINO
Buildin Department
JOB AD
OAD oS� C PERMIT# Os�oyooad
OWNER'S NAIvIE� �p R WOO to PHONE
GENERAL CONTRACTOR. E :90 FAX#
41)
I am not using any subcontractors: 6
Sign ure at
Please check applicable subcontractors and complete the following information
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &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
Owner/Contractor Signature Date
CITY OF CUPERTINO o o a 26
I(I ZIN TEMP POWER �S
OF
$CUPERTINO PERMIT APPLICATION FORM
APN 1136Gy yo 0 1 !5—
Date:
Building Address:49
QOFO 2&02 C4/V/ t&
Owner's Name:. Phone# 9l 3#1 ldoo
Contractor: eM r q08SO Phone: License#: _ / /!DD
Contact: -j-0E KF—`VSHtI Phone: Cupertino Bushiness License #:
Building Permit Info: Itl
Elect ❑
Job Description: / ' M 1 /x/11 p �o�Ur R �dzE
Residential ❑ Commercial �--
Cost of Project: ap
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE 'Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
C� �a ' �