04110054CITY OF CUPERTINO
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BUILDING ADDRESS: f.. _
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PERMITNO
SOUTH BAY. CONSTRUCTION CO
NC 04110054
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PBRMIT ISSUE DATE,�,RR
TER PROPER fIES -
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SANITARY ROL Nil. .
-ARCHITECT/ENGINEER., ...,.
- 0400-
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--,- BUILDING PERMIT INFO,
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BLDG ELECT PLUMB. MECH
LICENSED CONTRACTOR'S DECLARATION ,
- Job Description
• 1 Acmby affirm that 1 am licensed under provisions of Chapter 9 (commencing.
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with Section TO(10)ofDivision3of the Business and Profct&nom Cade.and myliccnttis
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in full Imre and effect
Llccne Clsaa - Lie'"
REVISION --IN HOUSE USE ONLY
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Dau:" - Conlracbr
ARCHITECT'S DECLARATION .'
NO NEW PERMIT ' ISSUED/ORIG.`. #0408017.7.
' 1 understand my plans shall W uud as public recorm
Licenud Professional, ^... -'•: ^. ..
' OWNER-BURXER DECLARATION
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I hereby affirm Net 1 am exempt from the Camomile, License Law for the
following reason. (Samoa 1031.5, Business and Profesaium Code: Any city Or county
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which requires a Permit to tontines. alter improve,demolish. or ¢pair any Structure
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pd., in its isat mce, also mquims the cm
bpPit for such Permit m file a signed smtement
Lt.... Law Cheroot)
- - Sq. Ft.. Floor Area
Valuation
matW is licensed punuantm ,he Provisiiumbf the Connector'.
Section TWO)of Divisidb3 ofthe Business and Profcsaions Code) or
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$43
(commencing with
tat hues exempt theefram mit the basis far the Olcged..,do . Any violation of.
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- APN' Number
-' Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than Bw hundred dollars (SKID),
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❑ I. as owner ordie property, u my cmployeea with wages es their sale compensation,
Ulred.Inspections
will do thawork,.nd thsatmctun is notinendedor'offered forsale(Sm. 1041, BusinessRe
and Profesaions Codes e: The Contractor's. License Law donot apply to an owner of
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pruMnywhobulldsorimproveademon..dwhodoeaswhworkhim.elfordnoughhis
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Ownemployees. provided that such improvements .mmol Intended oroRered forsale if.
huwnws iiinot war of
improvepurposeof-
builder wit haw me burden of provin6 Nat he did not Wild or improve foapurpott of
hawthe provingtat
.air.).
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1; as Owner of the propeny; am exclusively convening with licensed mntneers to
butt the pmlect (Sec. 7(j44, Business and Professions Cade:) The Condiment's Li -
move law doer not apply to an owner of property who builds or improves memos. And
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who mouses; for such projects wit acomnnor(A) bureed purmeanuo to Contractors
License Law.
❑tun ezemptu r c. ,B&PCfar ram n
wnu Dae
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Rjt •R' COMPENSATION DECLA T1
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I hemby affiant under penalty of perjury one of the toll ng d.WAO ns: --
Ihawandwillmei.mi..Ccn f.mcof Conwnuowlf-ireumfor Workers Compen-
snood, ax provided for by Section 3100 of the labor Code, for the performanm of the
work for which this permB is issued.
❑ I haw and will maintain Worker's Compensation Insurance. ds required by Stenon
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31W of NC labor Code, for the performance Orme work for which this permit is issued.
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My Workers ComPensatlon Insunmx earticr loci Policy number art: -
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Cartier. - Poliry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'.�
COMPENSATION INSURANCE
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(This section need not wrompleted ifthe permltls forone hundred dollars (SIM)
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or ass.)
I undfy that in the p ofommnce Of On, work forwhich this permit is issued. I shall not
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employ any person in any manner so as to become subject to the Warkers'' Compensadon
Laws Of California. Date
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Applicant
NOTICE TO APPLICANT: If. after making this CenlOcate of Exemption, you shuultl
bccome subject to Ne Workeh Compensation provisions of 0. labor Code, you most
forthwith comply sviO such inwition, or on, Permit shall bt dmmcd invoked.
CONSTRUCTION LENDING AGENCY
1 herebyaffirmthi Net mart is lending agency Isar me Performance of
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sued (m . 30
the work fur which This permit Is issued (Su. 3091, Civ. CJ
Lender's Name
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Lenders Addnss
j 1 unify that 1 have read this application and state sen the &how information is
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COMM I agree to comply with all city and county oNlnanas and state laws totaling to
building construction, and hereby authorise representatives of this city a enter upon the
above-mendoned property for Inspection purposes.
(We) agree a saw. indemnify and keep harmless the City of Cupertino against
j liabilities,judgmenu. costs and expenses which may in my my came against aid City
I. consequence of the granting of It permit.
APPLICANT STANDS D WILL COMPLY WITH ALL NON -POINT
Issued by: -' Date
FUD
SOURCE RE ONS.
I Re -roofs /
Type of Roof
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S' n tApplicant/ tracts, D
H RDOUS MATERIALS DISCLOSURE
Will the applicant or forum building occupant Imre arhandlc havuduus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Hutt and Safety
Code , Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
C] ye. No .. _
building which
" If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or mere occupant use equipment or devices
.it haserdous air contaminants as defined by the Bay Arc& Air Quality Management
all new materials for inspection.
. District?
❑Yea _X-
1 haw mad me hasaNaus materiels scquimmcnuundcr Chapter 6.95 of the Calimry
ilia Hmlth&SafetyCodc,Seca 25505.25533 md25534. tundeumndthuifthc building
does nn, comer, own. mm it u my rospan.ibility to nodfy the occupant of the
rcqujemente ustW t prior in issuance of a Comficate of Ownprmc.
Signature of Applicant Date
All roof coverings to be Class "B" or better
own anmodvca t
Da