04120087z
F
6
l
It
L
C
4 M,
CITY OF CUPERTINO
-
./.,kir
"""- +.PF mw:'a`� '`''
C� � Qui Q_N.YIN
- ..-.. _
- - - - - - - -
. -
BUILDING DIVISION - PERMIT
111\v-
ns'2us.=S�'�xfr< � •=h.�!+:L F�A3'Eb e`sk.�•^'k!.:4.�•
BUILDINGADDRESS:.
SOUTH BAY CONSTRUCTION CO
ffMIT N004120087
10251 TORRE AVE # 100
OWNER'S NAME:
PERMIT ISSUE DAM
ML
DR,. BEXTER YANG
511 DIVISION STREET
SANITARY NO. - - - "CONTROL NO. ' -
(408)379-0400
_
'ARCHIIECffFNGINEER:
BUILDING PERMIT INFO ••
BLDO ELECT PLUMB MECH
4z
_ LICENSED CONTRACTOR'S DECLARATION.-
" vi mby rte Nat I am liansod under pro of Chapter 9 (commencing
whh Su of Divinon 3 ofine Oueircu tow code. and mylkenm la
JobDescription :• r:'•.- -
inmRm effck
Clu
TI --DENTAL OFFICE
dense
ARCH17ECr'S DECLARATION
�1oArrumd my plans Nall M nsedufuWl4¢wrJ.
vJ�/ //
'
ll�•
/Cow•
sy�
3OWNER-BUILDER
rJ
//��,,
��'
" J/�•��
LiC .r am - -
DECLARATION
9
1 hachy arnhan that I em ucmpt from the Contractofs Uanm law far the
aT
p 0
$ �i
following mason. (Sad w 7131.5 Business and Professions Cade: My city or county
wMch mquiro • posmit m ennnNc4 alar, ImpNw. demo) W, os mpsir any stmefum
1 '/ J, 8106700
Zj,
priort, its issuance, abs mquires the applicant for such permit in file a signed lutemem
fhaf he la licensed to the the Conlrectur'l Urcnn Law, (Chapter 9
Sq. Ft. Floor Area
�:'�ValUBtlOn ,
FO
��
pustumt provialonsnf
(..net.&with Sudan 7000) of Division S of Um Bush. and Professions Code) ar
that M la eastern tMmfu. aod the hula for the alleged eanmption. Any violation of
__J1*4W_N1AT16eT0 U
OceupancyTYpe
Section 7071.5 by any Applicant for a permit subjects the applicant to a civil penalty of
tet more thin five hundred dollars (5500).
❑I.Mmwofdnpmpwywmyemploycuwlthwegunftkulammpe don,
_
Required Inspections m..: • -' "dl:' ^.
.- -
will do the work and the smunum is mtmtsoded maffered fanald(Sec. 7044, Budrcaa
and Profession! Cade: The Comracmrt License Law dads tet apply w an owner or
-.._. .. .: !Sl• .. -
-
property who builds w lmprovethrocomaodwhodoessmh work himselforlNough his
mmemployca. provided thnsuch improvements am act one orofE=d forule.IL
_
however, the building or Improvement is old within one year ofcompletron. The owner -builder
add love the buNrn of proving that he did nm MW or improve fu purpose of
•, ' - .--.
ask.).
..
❑ 1, u owner of Use progeny, sin exclusively contracting wit second === to
rnmwct do project (See. 7044, Business and Professions Code:) The Camracmte U.
- -
coon law does not pply to an owner of propenY who builds or improve daemon, and.
who contacts for such projects with. contractor(s) licensed renwnl to the Contrnmh
- - - - -
Lice, law.
-
(]Ismevemptunder Sec. , B k P C far this
owner Data
-
.WORKER'S COMPENSATION DECLARATION-"-�'—: ^`.—•=
—-'.••-,._ _
1 hereby affirm under penalty of peryury am of site following declarations:-
hawand will ..Irwin sCa Ullate ofConsanf. self-Iuum far Warkee.Compete
- -'-•- ---
mi., u provided far by Sudan 7700 of the IaMr Code, far the performance of the
-
work for which this permit is issued. .. ..
❑ I haw and will mahom.n Workers Comians.don hunana, u required by Sudor
• - -..
3700 ofthe labor Code. fort he performance or site work for which this perad( sissued.
- -• .. , "' -' '
My Wa Compe Elm lnwnnce corn�u/ and Polity numberam:
s
Came /Pp Iiry N
CERTIFICATE FXEMPpION FROM
COMPENSAT10I1t1 INS URA
' (Tbbsection mud not becomplewdiftM permit oforonc hundreddellm(SIM)
..
or less)
1 arify that In the perfamtancc of me work far which this permit b Word. I shall tet
,
Trophy, any person in my manner so as W become subjat to the Worland Compensadan
Lawsof Califomh.Dave
Applicant
NOTICE TO APPLICANT: If. for making this CenlOam of&..Pa.., you should
become Subject to me Workei s Compensation provisions of me labor Code, you mon
OfoMwith
comply with each provisions or this permit atoll M dccmrd reward.
y
CONSTRUCTION LENDING AGENCY
- -
1hereby &mmme, them la.com used. Eroding agency ter the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
QLe
does
landeet Addmu
z
-
Q
I «Afy that I have mad this application and ante that the AMw information Is
'
correct. I agog in comply with all city and county ordinances and safe laws mladng or
SV`
f1d
building convection, and hereby sumolm mpreunfafim of this city to enter upon the
show -mentioned property for tupec ion purposes
(We) agree to raw, indemnify and p harmless Uma City of Cupmino against
f0
llabllides,judgmenu.costsanderpenns idh may In any wayasc.oagaln.t mid City
inEkOrhe, ranting oma '.
Al0"Sr ILL COMPLY WITH ALL NON -POINT
Issued by: Da e
SOU pro
Re -roofs
Signa a AppOcanUC or a
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Wdl the applicant or future Wilding occupant stare or handle havndous matedas
a defined by me Cupertino Municipal Codd. Chapter 9.12. and site Health and Safety'
odes Secd.. 25532407 �
All roofs shall be inspected to any roofing material being installed.
Y. �No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant are equipment or dcviaa which
t haeardom air conwminanu u ddMdd by the Bey Area Air Quality Management
all new materials for inspection.
iWoot?
❑Yds IA_Nu
Ihaw mad hasaodous ismqui..mu.&,Chapw,6.95orthe Califo,.
nla Heal. t Code Sa.d 25 5.25533andM534.lundersmntlmuifinebuildi 9
not c ow a te 4 ft b my responsibll occu ant of c
,
men, rah 06 met ormiumoceofaccrlliceka
Signature of Applicant Datep-,,
All roof coverings to be Class."�I',ortbetl,,a,.ei'"'''"
0 Tar m or'v a rat p
4 M,