05070010 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACTOR INI',ORMATION 1,*'
BUILDING ADDRESS: ACME & SONS SANITATION/ELE i"005070010
OWNER'S NAME: PERMIT ISSUE DATE
KEVIN THOMPSON 3408 HILLCAP AVE 07/01/2005
ONE: SANITARY NO. CONTROL NO.
(408) 295-2263
ARCHITECTIENGINEER: BUILDING PERMIT INFO
sIw BLDG ELECT PLUMB MECH
woo LICENSED CONTRACTOR'S DECLARATION
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I hereby affirm oras 1 am licensed under provisions of CTapmr 9(commensi is Job Description' 7,�
with Section]gMq of Divinion Sof NC Businussand Pru@ssinnx Code.antl my license is
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i r ARCHITECT'S DECIAR N
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K� I undersand my plans shall he used u public records �
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Licd Professional
5 OWNER-BUILDER DECLARATION
y I berehy affirm that 1 Lou cattail from the C.oramwes License Law far the
i 00 following mason.(Section 7031.5.Business and Profcssiou Code:Any city or Coumy
2 which requires a Permit it Construct,after.improve,demolish.or repair any structure8500
_Z< prior to its issuance,also requires the applicant for such permiuo file a signed statement
that he is licensed pursuansso thcproviaiouaf the Contecturs License Li.(Charter 9 Sq.FL Floor Area " -Valuation
x�0 (commencing with Section 7030)of Division 3 of to Business and Profusions Code)or
y 9 Nat M Is exempt therefrom and the basis fm the alleged caemption.Any violafi,on of
Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of
aol more than five hundred ddlau(5500). la Occupancy Type
❑1,u owner of Ne pmpwy,or my employcu with wagu m their sole compenudon.
will do thc work,and the swcture is not intended in offered ror sok(See.1(144,Business
and Professions Cme:The Canuacmrs License Law dpu not apply in an owner of Required Inspections
property who builds or improves thcmen,and who doessuch worthimself or through his
own employees,provided that such improvements tie not intended oroffered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did Out build or improve for purpose of
sale.).
❑I,as owner of the propeny,am exeluvively commeting with licensed contractors in
construct the pmject(Sec.7044,Business and Profusions Code:)The Contractors Lt.
cer se Law does not apply to an owner of pmpeny who builds or improves themon,and
who contracts for such projects with a cuntrnmar(s)licensed pursuant to the Contractors
License Law.
Cl I am exempt under Sec. .B&P C for Nu mason
Own Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of she following declmniom:
I ham and will maintain a Cesdfiou of Consent to self-insure for Winter's Compen-
sation,u provided for by Section 3]00 of the Tabor Codc,for the performance of the
work far which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,u mquimd by Section
3100 of Ne Labor Code,for the performance of the work for which this permit is issued.
My Wi rk s Compensation Insurance carrim and Policy number a ��
Cartier. Policy No.� S -
CERTIPICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mosimett med not he completed if tic permit isfortme hundred dollars($10(f)
or Lim.)
1 Certify that in the performance of the work for which this permit is imucd.I shall not
employ any person in any manner so as to become subject to the WorkcrY Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If.afar making this Cenifieam of Exemption,you should
become subject in thc Worker's Compensation provisions of the Labor Codc,you must
.JO forthwith comply with such provisions or this permit be deemed revoked.
Z'y CONSTRUCTION LENDING AGENCY
F-' Ihereby a(Erm that there iso eortstucdnn Lending agency for to performance of
(Y> due work for which this Permit is issued(See.309],Civ.C.)
�W A Lmrders Name
D z Lenders Addreaa
U O 1 ccnify that 1 have read this application W sum than the above information is
U, H Correct.I agMC to comply with all City and county(Mummies and sum laws relating in
O U building construction.and hereby authoriae representatives of this city no enter upon the
Li) above-ms,judgcdpmp rtyoat for iupccvon purposes.
G (We)agree to save,indemnify and keep hart les,the City of Cupertino against
(n incominquenc of thec raming ofpcnsesmit. may in any way accroc ageing aid City
U Z APPL CANT UNDERSTANDS AIND TWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGU TIONS.
�A a Re-roofs
Signa plicanUContrxmr IDate
HA ARDO RIALS DISCLOSU RE Type Of ROOF
Will the applicant or fulum Wilding mCap.,Yom or handle ha mous material
u defntm by IM Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
ode,S W,25532(1)? All roofs shall be inspected prior to an roofing material being❑Yea � �� P P � Y g g installed.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or fume building by the B tax equipment or devices which g
it harardnu air conumimnu u tetroti by the Ray Area Air Quality Management all new materials for inspection.
WICI]
❑Yes No
1 have mad the humorous materials requirements under Chapter Q95 of thc Califon
ni.Health&Sarety Code,Statimu25505.25533 and 25534.1 undenund thxtifthc Wilding
dors not currently have a tenant that it is my responsibility to notify the.,am of Um
myuirt ww�WgLPMUSL to mm prim to issuance of a cerdreatenr ac pan
Owner or authiced agent Signature of Applicant Date
�� � All roof coverings to be Class "B" or better
Dam
�„ Community Development
10300 Torre Avenue
Fes' Cupertino CA 95014
,H
5Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRESS: PERMIT#0�0`7 0 0/0
OWNER' NAME: � a PHONE # — /
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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
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ICUPEkTINO PERMIT APPLICATION FORM
APN # Date:
a� - ) - C)
Building Address:
Owner's ame: Phone #:
Contractor: hone: License #:
CvV"L cam^ (A�- /o
Contact: Phone: Cupertino Business License #:
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Building Permit Info:
Elect fbt - r
Job Description:
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Residential Commercial ❑
Cost of Project: t—o
LX�
Qty. if
ApplicpLble Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING