02040126 C1 no DIN DPexO`No PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10481 SERRA ST. ACME & SONS SANITATION/ELECTRI 02040126
OWNER'S NAME: APPLICATION SUB DATE
- O ' BRIEN GROUP 3408 HILLCAP AVE 04/23/2002
F PHONE: SANITARY NO. CONTROL NO.
(408) 295-2263
027 ARCHITECT/ENGINEER: BUILDING PERMIT INFO
RLwO-O
BLDG ELECT PLUMB MECH
¢i L=
¢�
LICENSCD CONTRACTOR'S DECLARATION
5„? Job Descri tion
i Z_C 1 hereby affirm aM1aa I am licensed under provisions f CM1apmr 9lctmmencing P
_tad with Section] WIo�r r3afahx%inf,v cipnsCtdeyandmybceme TEMP POWER POOL
is in full fore and e Nom(C� ///U C(&
'z�6 a M
3 a v 5C
Canonical—
oni
u. ARCHITECTS UEC ATIDN
g 1 undcmand my plana snail be used E public records
I i p 2 Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
y
Z O whichfollowre moviwires a Permit
tn'Ionfron03 Business and Professions demolish..or AnY city st cautery $500 5 O O
wh'ch q permits t t h ,imprmehperitsfile
repair anystrvnum Y
3m prtno4 ane Ica requires Pr applicant sucCommence mile as w oChdpmstatementhot b,
(comm cial,,licenseaprsuann Thep softhefmBarors andProDow(ChaMer9 'l Valuation
(comm cg..1h Section ZOW) fhe sis3of the Busneseandimi.Any vi Cnde) �-Ll's?f.;-3?��'Pt31�, ' .t�'�1',�?.'x}.,� [ lt?'w.
or olid he is exempt thcrcfrom and or basis for the as he demotion.Any violation
-of Section 703 than
n by any applicant for a permia mbjcns the applicant m a civil penalty
.arnot mom tnaPfive nanarcadollars($sW). 10-�PN Occupancy Type
O Los owner of the property,or my employees with wages as their sole compensation, 304 _ Roll(-T4 AT
will do'the'work:-.d Or someone is not intended or offered for sale(Sec.](s W.
rHudnesi and Professions Code:The Contractor's License Law ares not apply to an Required Inspections, - f
owner of pmpeny Who builds m improves thereon,and who ares such work himself
offered Fo his own employees wever.t provided That such improv<mems art not intended or
offered Formic.if,However.the building or ire ..Tent is sold within no year of - -- - - -- ---- _ ------ ---- -- --- - - - --
completion,the owner builder will Interim burden of proving bill he did Hol build or
improve for purpose of sale.),
coLasowner of the p(Sec.704m exclusively contracting withocened contractors to _ ..
incense the project(Sm. fits Business and ProfessionsCode:)or The improves
Contractor, ,
i. License law does nm apply men owner of property who builds or improves thereto,
. ”
end who contracts for such Projccls wilM1a comracaor(s)liccnmd.pursuam m.IM1e .......
Contractors License Low. - - - -- ------- _-- --
❑1 am exempt under Sec. - .B&P C for this.,an ,. .,. s
Owner' Da¢
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Cridfcom of Consent to self-insure for worker's
•Compensation, as provided for by Section 37W of the Labor Code, for the
pelf rrmanedof the work for which this permit is issued.
❑1 have and will'imaintalo Worker's Compensation Insurance,as rtquircd by Section
_ 3700 of the Lchor Code,for the performance of the work for which this permit is
`true/d My N 1 s Compensation Insurance
'cr and Policynundberaire '
NNe.�r7��r��rou�yna�� S'/ of ' ' - �-,.�., t �..., - •t .i r 4,� -- .-, .- ( r - -
CCRTIFICATION
''''I - -COMPENSATION INSURANCE'"� s" '
" mis section need not be completed if the permit is for one hundred dollar
fE1 W)o�IcssJ ,-, ,
" i m fy Thai in Person
p f noncenn the work fore oM1 Ibis perm tis issued 1 P• +I , i .,,I,`• 1,3{ ,
shall not employ any person in any manner xo as w become subject to We Workers'
A iica t I Law1.s of California.Date
NOTICE TO APPLICANT:If.after making this Cmrficamof Exemption:you should ` "
Z ecome H corn l the Worker's Compensation provisions of the labor Code,you must
0 bfor,w ecome tubber y fill,rch provisions or this permit shall he.deemed revoked.
J
F' .ria "' t•CONSTRUCTION LENDING'AGENCY'
a ' 1 hereby afGrrii that Nem is a construction lending agency for the performance
of ole work for which this permit is isxued(Sec.3090.Civ.C.)
A Under',Name
- - .. .._..__ ._... —.. .. - .._... .. __
D" Unde s Address -
V ..
I grey th Iibm hall.' ty a dtatlisM1 b - f to is V
W F., abuil nacret comply,with H city rid., my ordinances and sial I leton
Q V mbubde me a hon; dhembyaection rpsenmfves of chis<ay ni sorer upon
}.cao the abavcmrn agree
toned propcny for inspection and
ppanni purposes.-
F^ CA es,judgmetsscoastaetns,sires keewhich
in
Cityay Cupertino Iain.d
CA City in c judgments.foam and expenses whim may in any way accrve egaln5 said �^
V Z Ciayi co W cc of the g (ng of this permit, I/
:APPLIr Nr U S' )5 AND,WW LL COMPLY WITH ALL NON=P01
s uR REr 1 "' Issued by: Date
n vrcan t r
i Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
1'•-'
will the applicant or firom building occupat store or handle hauraous material Type of Roof__. -
as defined by the CuKdrtirw M tnicipal Code Chapter 9,1I d the Health and Safety
Code 5 1 25532(.)?12 _ - - " s• t 1 t '
„ _ -, „All roofs shall be respected prwr_[o any roofing material.being,installed.
W
The applicant f t bmlding p rase equipment devices which If a roof is installed without first obtaining an inspection', I'agree'to remove
cora h¢ma constrain t de -b5 TheBay Arca Ai Quality Management
Dodi I all new materials for inspection. Applicant understands and will comply with
Y ^, °?",- "n .. all non-point source regulations....
I habc'rcad the haiaratus ma¢rials mquircmenas'under Cha6ter'6.95'of the
California Health&Safety Coae.Sections 25505,25533 and 25534.1 understand that
If,
f the building does not currently have a tenant,ohm it is my responsibility to Puffy the
need' I ofine re i men 'hi 'mon rte' M prior m issuance or a Cenlfcme of
,r ac Signature of Applicant _ Date
' o i,eaa _ext - Dam All roof coverings to be Class "B" or better
OFFICE -.
C1 no DIN DPexO`No PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10481 SERRA ST. ACME & SONS SANITATION/ELECTRI 02040126
OWNER'S NAME: APPLICATION SUB DATE
- O ' BRIEN GROUP 3408 HILLCAP AVE 04/23/2002
F PHONE: SANITARY NO. CONTROL NO.
(408) 295-2263
027 ARCHITECT/ENGINEER: BUILDING PERMIT INFO
RLwO-O
BLDG ELECT PLUMB MECH
¢i L=
¢�
LICENSCD CONTRACTOR'S DECLARATION
5„? Job Descri tion
i Z_C 1 hereby affirm aM1aa I am licensed under provisions f CM1apmr 9lctmmencing P
_tad with Section] WIo�r r3afahx%inf,v cipnsCtdeyandmybceme TEMP POWER POOL
is in full fore and e Nom(C� ///U C(&
'z�6 a M
3 a v 5C
Canonical—
oni
u. ARCHITECTS UEC ATIDN
g 1 undcmand my plana snail be used E public records
I i p 2 Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
y
Z O whichfollowre moviwires a Permit
tn'Ionfron03 Business and Professions demolish..or AnY city st cautery $500 5 O O
wh'ch q permits t t h ,imprmehperitsfile
repair anystrvnum Y
3m prtno4 ane Ica requires Pr applicant sucCommence mile as w oChdpmstatementhot b,
(comm cial,,licenseaprsuann Thep softhefmBarors andProDow(ChaMer9 'l Valuation
(comm cg..1h Section ZOW) fhe sis3of the Busneseandimi.Any vi Cnde) �-Ll's?f.;-3?��'Pt31�, ' .t�'�1',�?.'x}.,� [ lt?'w.
or olid he is exempt thcrcfrom and or basis for the as he demotion.Any violation
-of Section 703 than
n by any applicant for a permia mbjcns the applicant m a civil penalty
.arnot mom tnaPfive nanarcadollars($sW). 10-�PN Occupancy Type
O Los owner of the property,or my employees with wages as their sole compensation, 304 _ Roll(-T4 AT
will do'the'work:-.d Or someone is not intended or offered for sale(Sec.](s W.
rHudnesi and Professions Code:The Contractor's License Law ares not apply to an Required Inspections, - f
owner of pmpeny Who builds m improves thereon,and who ares such work himself
offered Fo his own employees wever.t provided That such improv<mems art not intended or
offered Formic.if,However.the building or ire ..Tent is sold within no year of - -- - - -- ---- _ ------ ---- -- --- - - - --
completion,the owner builder will Interim burden of proving bill he did Hol build or
improve for purpose of sale.),
coLasowner of the p(Sec.704m exclusively contracting withocened contractors to _ ..
incense the project(Sm. fits Business and ProfessionsCode:)or The improves
Contractor, ,
i. License law does nm apply men owner of property who builds or improves thereto,
. ”
end who contracts for such Projccls wilM1a comracaor(s)liccnmd.pursuam m.IM1e .......
Contractors License Low. - - - -- ------- _-- --
❑1 am exempt under Sec. - .B&P C for this.,an ,. .,. s
Owner' Da¢
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Cridfcom of Consent to self-insure for worker's
•Compensation, as provided for by Section 37W of the Labor Code, for the
pelf rrmanedof the work for which this permit is issued.
❑1 have and will'imaintalo Worker's Compensation Insurance,as rtquircd by Section
_ 3700 of the Lchor Code,for the performance of the work for which this permit is
`true/d My N 1 s Compensation Insurance
'cr and Policynundberaire '
NNe.�r7��r��rou�yna�� S'/ of ' ' - �-,.�., t �..., - •t .i r 4,� -- .-, .- ( r - -
CCRTIFICATION
''''I - -COMPENSATION INSURANCE'"� s" '
" mis section need not be completed if the permit is for one hundred dollar
fE1 W)o�IcssJ ,-, ,
" i m fy Thai in Person
p f noncenn the work fore oM1 Ibis perm tis issued 1 P• +I , i .,,I,`• 1,3{ ,
shall not employ any person in any manner xo as w become subject to We Workers'
A iica t I Law1.s of California.Date
NOTICE TO APPLICANT:If.after making this Cmrficamof Exemption:you should ` "
Z ecome H corn l the Worker's Compensation provisions of the labor Code,you must
0 bfor,w ecome tubber y fill,rch provisions or this permit shall he.deemed revoked.
J
F' .ria "' t•CONSTRUCTION LENDING'AGENCY'
a ' 1 hereby afGrrii that Nem is a construction lending agency for the performance
of ole work for which this permit is isxued(Sec.3090.Civ.C.)
A Under',Name
- - .. .._..__ ._... —.. .. - .._... .. __
D" Unde s Address -
V ..
I grey th Iibm hall.' ty a dtatlisM1 b - f to is V
W F., abuil nacret comply,with H city rid., my ordinances and sial I leton
Q V mbubde me a hon; dhembyaection rpsenmfves of chis<ay ni sorer upon
}.cao the abavcmrn agree
toned propcny for inspection and
ppanni purposes.-
F^ CA es,judgmetsscoastaetns,sires keewhich
in
Cityay Cupertino Iain.d
CA City in c judgments.foam and expenses whim may in any way accrve egaln5 said �^
V Z Ciayi co W cc of the g (ng of this permit, I/
:APPLIr Nr U S' )5 AND,WW LL COMPLY WITH ALL NON=P01
s uR REr 1 "' Issued by: Date
n vrean t r
i Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
1'•-'
will the applicant or firom building occupat store or handle hauraous material Type of Roof__. -
as defined by the CuKdrtirw M tnicipal Code Chapter 9,1I d the Health and Safety
Code 5 1 25532(.)?12 _ - - " s• t 1 t '
„ _ -, „All roofs shall be respected prwr_[o any roofing material.being,installed.
W
The applicant f t bmlding p rase equipment devices which If a roof is installed without first obtaining an inspection', I'agree'to remove
cora h¢ma constrain t de -b5 TheBay Arca Ai Quality Management
Dodi I all new materials for inspection. Applicant understands and will comply with
Y ^, °?",- "n .. all non-point source regulations....
I habc'rcad the haiaratus ma¢rials mquircmenas'under Cha6ter'6.95'of the
California Health&Safety Coae.Sections 25505,25533 and 25534.1 understand that
If,
f the building does not currently have a tenant,ohm it is my responsibility to Puffy the
need' I ofine re i men 'hi 'mon rte' M prior m issuance or a Cenlfcme of
,r ac Signature of Applicant _ Date
' o i,eaa _ext - Dam All roof coverings to be Class "B" or better
OFFICE -.