01090053 (2) OF
CI BUILDING DIIVISSIIONNDPERMIT CONTRACTOR INFORMATION:
BUILD YG ADDRII S PERMIT NO.
10548 MANZANITA CT ACME & SONS SANITATION/E ECTRI01090053
OWNER'S NAME: APPLICATION SUB DATE
ft O 'BRIEN GROUP 3408 HILLCAP AVE 09/13/2001
FHONE: (408) 295-2263 SANITARY NO. CONTROL NO.
`
O c Z ARCHITECTIENGINEER: BUILDING PERMIT INFO
O O BLDG ELECT PLUMB MF.CH
m
r i
2 N y a" LICENSED CONTRACTOR'S DECLARATION
u,C 1 hereby a rm that I am licensed under provisions ofChapter 9(commcming Job Description
-_C, with Section]000)OfDiviamn3Ofthe BmineaandPrnm„ian,Code.And myrcense TEMP POWER POLE.
:Y IJ as
in full force and affect.
z°:6 ata Class Lie M
De
i 3 S6r,y DaS DECLARATION
LL o S ARCH ll be ue DECLARATION
1 understand my plans shall be used as public records
T
3 G c O Licensed Professional
OWNER-BUILDER DECLARATION
1 hcmby affirm ahs 1 .Bcmpt from die Contractor's License law for the
C?4 following renwn.ISe<tion]03I.S.I. Business end Professi.m Cade:Any city w county
f F O which q res a perm.t .t ct .Iter mp d mofsh or reps r any swctu $500
twj3w ^Wiwi t r.ancealsoreq thea,rlica of hpemut mGle asignedwm t._.. _ _. _ _ _.. -_-._ _ __ ... .___. _... .-._- _
that he irlwintsed formim m the pro s ons of th C t nth License Law(Chaps 9 t raf3C' i q { Valuation
orthattie is exem with 50iercfrom0nnd the hasros fur dm.1 ,11 ed exec PrPfworuoCode) t:t1 tib'}�)36.1'tfL L•-IlJV�wC\
p 6 P Any
of Section]031.5by any applicant fora permit subjects the applicant so a civil penalty ,
ofno,Ammib.Fivehunercddollars(s500) 103APN �r Occupancy Type
❑1,as owner of She property,or my employees with wages as their sole compensation,
will do the work,and the swcturc is not intended no offered for sale(Sm.7044,
Business and Professions Code:The Contractor's License Law dues not apply to an 505 - FINAL EI]RMd U Aflections•
orvr of pm,xmy Who builds or improves thues ean,and who dosuch work himself
Nmugh his own cmpinyees.provided that such improvements ere not intended or
bffacd for Aide.If however,N Wilding or burden
f Prov is sold within orae year of
completion,the r bat Id 11 h the burden of uem I, that wi did no build or {
im,move for prolsom of sal..).
Cl 1 o u of the propcnY Am eAi,lmnel,zontractang with licensed econme....to
construct the project(See 70n4 Buonem and Pmfass tots Cade)The Contractor's
Llerme law does not apply to an owner AS property who builds of improves thereon,
and who contracts for such projects with a cantmelor(s)licensed pursuant to the ... ... _
Contractors License Low. /0/1 /
01 am exempt under Sec. .B&P C for this mount 1
0”, Data O
WORKER'S COMPENSATION DECLARATION /
1 1 hereby.Rem under penAty o(perjury one.(the rolluwing deelanlions:
■ a ❑ I have and will maintain a Cenifi,."of Consist to sclf-insum for workers
t�yy Compensation. As provided for by Section 37W of the Labor Code, for the
- _ petfurmance of the work for which this permit is issued.
❑1 have and will maintain Worker's Compensation]..,A..,As required by Section
37W of the Labor Cade,for the performance of the work for which this permit is
issued.My Worker's Compcnmtion lnm.-Ace.6af ier and Policy number are:.-^
-CN .pot yNo .. pp
,
'CERTIFICATION OF EXEMPTION FROM,WORKER,S'f - t l i s .- r' 1 1 _ y' .1l5a 4.'.ri l a
' 'COMPENSATION INSURANCE,". .-_.-_....-
' A f ndi titin;.need nil be completed if the permit is for cm,hundred dollars
(SSM)or less.) „
' I'ecrtify that in the performance o1 thework for which this permit is issued,l :t •,, t
i,.H eta employ any person in any...no,so As M become subject to Workers'
Compensation Laws of Califomia.Date
Applicant - .. -
NOTICE TOAPPLICANT:If, ftenwking this CeriGcae of Emmptmo You should
Q Obeecomsubject to the Workers Coml...lI..pros siom of the Labor Code,you most
foMx'ith comply with such provisions or this permit shall be deemW revoked.
V� ' ' •re CONSTRUCTION[.ENDING AGENCY. '
a kms" '1 hereby wAM.hich this there is o issued
(Sec. lending agency for the perfurtnantt -
fi7 of the work for which this permit is issurA(Sec.J09],Civ.C.)
S Q der's Name-'
Lm
V C 1 ttnify aha I have read this application and lam that the above information is
Iz Ey cored.1 a,me to comply with all city and county ordinances and state laws relating
A L1 m Wilding ronsuuction.arid hereby Authorize representatives of Ni,city to enter upon
W the otions-mentioned propcny for inspection purposes. ,
t:
%M. (We)Agree torove:indemnify and keep harmless the City of Cupertino against
(n liabilities,judgmema,costs and expenses which may in any way amore against mid
City int cmvsm,ocnce of the grand,of thii .it.
APPLICANT UNDERSTANDS AND WILL COMPLY W1111 ALL NON POINT Issued by: Date
SOURCE REGULATIONS.'"" r Y'
Sign amreof Apprc..rAo.tmcIm " . Date' Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the appl cant or future building we pant store or handle hazardous material Type of RoofAs defmW by Ne Cupertino Municipal Code Chapter 9.12,and the Health And Safety > a
C.deaecfan 255321) . „ w
0Yea 0 No •) ' ' ' All roofs shall be inspected,prior to.any.roofing material being installed. .. ._.
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
mit hdaandoos air contaminants as defined by the Bay Arca An Quality Management
Diatriee all new materials for inspection. Applicant understands and,will comply with
❑Ya 0NI I. all non-point source regulations. ,
1'h.vearead the hazaidouk materials requiremi.0 under Chapter 6.95 of the
California Health&Safety Coda,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
_ °'sipart of the rc m.n entk which most be met prior to issuance of.Certificate of
""Fancy' Signature of Applicant Date
Owner At anmur;.cd.,,A, '. , - � � D... All roof coverings to be Class"B"or better"
p� OFFICE '
Fc.,
ITY OF CUPERTINO
eUD.mN DIVISION ��RMIT CONTRACTOR INFORMATION:
LDIW DDRES'S: PERMITNO,
47 MANZANITA CT. ACME & SONS SANITATION/ ECTRI01090053
ER'S NAME: APPLICATION SUB DATE
IBRIEN GROUP 3408 HILLCAP AVE 09/13/2001
HONE: SANITARY NO. CONTROL NO.
� (408) 295-2263
RCHITEC(ENGINEER: BUILDING PERMIT INFO
u BLDG ELECT PLUMB MECH
u
C] L=1 IJ I-1
y= LICENSGD CONTRACfOft'S DF.CLARA Job Description
1 hereby affirm thoiat 1 am licensed underprovisions of Chapter 9lcommeneng
„�8 wdthSection7000trf .d%Ion3oftheBainessaWProfessionsCade, ndmyhceme TEMP POWER POLE .
in full f0me o J Ree
o u Deer , see.x ( 0
Dae Comracmt
i3 O ARCHITECT'S DECLARA
r' 5 1 understand my plan,shall he u.,,d as public rccOrd>
ibei O O Licensed Pmfasi...I
OWNER-BUILDER DECLARATION
at M v. I beery affirm that 1 em exempt from the Conuacmr s License law for the
L z following mason,(Section 7031.5•Business and Purevu as Code:Any city or caumy $500
IFC which oct a pirrou to imummo. 1 p demolish,or repror any structure _ _ _ _
n3°O Prior tot ' Iso req the pplim tf hp, no Gk a:gaed cera m_ _ _ _ ______
sore he Ih scrip moth p e fdeC trot ms 4mnse taw(Chap, 9 _ x q C'p�P� , !} valuation
(commoncing with Sect on 7(a)d of Ovist n 3 of the Bopumu and Pmfessimu Cad)
or that he'A exempt therefrom and the basis for the ullegcJ exemption,Any violation
-of Section 70315 by any applicant for a Permit subjects the applicant to a dvil penalty, .{.
'of not more than five hundred dollars l$500). 1031PN tFLh rIt's Occupant Type
01.as owner of the property.or my employees with wages as their sole rompensmion, - ; _ _
wlT So the work,,-and the structure is not intended or b?ercd for sate(See:'76i4,,'
Baduci,nid'Prorasion,Code:The Commcmr'I License Law dans not apply m an Required Inspections''
owner of prererty Who brads or improves thereon,trod who tire%such work himself
or through his own employees.provided that such improvements am not imendW or
offered for,ale.If.however,the building or improvenrem N sold within one year of („•
completion,the owner-W ilcicr will have the burden of proving Bat he did not build or
improve for or,o,c of sale.).
consumer k a owner of the O(sm.7 am Buti mcly do fih�with out Th cono-wmn m � .. . .
Li,imc the project(Sa.7044.owner o end who
Coded improves
Convenor's I •. . .. ..
Licensee Lcwtras notapply eaanownerof property ouwhobu ildsseor i pursuant to
_
and who contrast l- ,uch projcaa.with a mmmnrrts)licenced pursuant m the
C Iona;placid,law. . F I N
❑Ino cxanpt under Sec', •• . . .0'&PCfor this reason
Owner Date
WORKER'S COMPENSATION DECLARATION 4
J p 2001
5 I bacby affirm under penalty of pdrjury one of the following declarations: 1
7 1 hive and will rovide n a Cby euro of 3Consentm cel(-be, for Worker's
Comp notation.-le provided farwhich
by genion ill. of the boo Code. for the BUILDING /V U
rf c addle work to, h h th pp t cd
01 base and '1lnainu ;Wrrke aCoruperualiurr 1 c.as required by S
3700 f th tabor Cade f the pert f the wok f which this pc t Cy
” C L+c sat n m carrier dPolicy M m L _
, My Work fs
CamerPolicy
1 )CE FlCATION
CL WQ -'.L"ened 1 hNamb_yef Rom•
on NI nJ bO-ngMe aWORKERS'ORKERS
r^mATION INSURANCE'
,'p<rform..anc
< a
(Th entanerd nes bepl teJ dth � RmddolIan
(S(X)) 1 ) �� ��/,V�U`l•1 ". I 1 ,. t
'
+
YL
oj issuract.'I
1,mifyfludiliffic pe( a (he h( which
6h11 c yes^Ypc y an aobject tthe Workers
e anLatsofC f D¢
Alit
NOTICE TOAPIICANT,1f ❑ main, sif t yArnold
zbee a subject Ih,W AerC Pe tionprx he Code,
Q (nhmply ithch previsions permit he deemed
Z
iCONSTRUC=NLFNDINGAGENCY
Otto Af 1 hih pt .icmed(9 J9Civ.C) /
V
\_
= z LeaderAdd "., o�' ,.Ido t
I nrytktLh e rid . ppliset J.at thmth W ' fowl mist t/jj
it, correct I greenscomply'
lh II set antic Y ordinances ❑stoic 1 elating
tF.7 mWIdag t Iia rh by,pecum,rpm. tlntis of this city to enter upon
th< hn t tip pcnYf pn PIP es
F,y IH ) gra ts.c a mJemn pe rent AL i he I - any wa f C pen- a t aid
V1 liabilities.judgments.cat M expenses which y n any way a< It inu se id
C.7_,Z, Gt conscqucnce of the gaming orchis paten.,
CANT
UNDERSTANDS-AND WILL COMPLY WITHALL I:0 -PONT ' Issued by: Dale
.OUR'E ULAn �� /. y:
- rep m FA,plicnm/Cmilo r .. ,""-1. .' . . ante'/: Re-roofs
HAIMMS MATERIALS DISCLOSURE '
Will Ne applicat fare Wilding occupantt or handle hroardeas material '(Type of Roof.
as defined by the Captain.M ndpal Code.Chapter 912.audio,Health and Safety
Cadat ten a S2.5532(a) t - l se ;M�- '' f .r
ic
0Yc.' ....'.'' ,All roofs shall.be inspectedprior to any.roofing.material,being installed. _.
ri, apphc•oforfum.Wifiing«coryntroeryr;Pmentordevice,which If a roof is installed without first obtaining an'inspection',1 agree`to remove
mot hazardous air contaminants a defined Y the Bay me Air Quality nag
ement
n;,vat all_new materials for insPection. Applicant understands and will comply with
all non-point source regulations. ...1t,. .
1 have read the hmaad.ms materials requirements under Chapter 695'of the
Califomia Health&Safety Code:Sections 8505.8533 and 25536.I understand that - 7
if
-
iftheWildingdoesnotcuncntlYhaveatenanrthatitismytespomiliddytonovfythe / ,9
nc
m oft c re.. .m. ..which must he ma prion m i.ssmnce of a Certificate of
p azure of Applicant Date
gr�p'• � : �� All roof coverings to be Class••B"or better
r_ o h med agent 1, m: -
OFFICE