04120112CITY OF CUPERTINO
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DIVISION.- .'PERMIT"---
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BUILDINceDDRFss
SOUTH BAY CONSTRUCTION' CO
M1N�4120112
1
OWNER'S'NAME:
PERMIT]aem DATE -
HUNTER PROPERTIE
E;
SANITARY NO. CONTROL NO.
(408)379-0400
'ARCHITECT/ENGINEER:.
BUILDING PERMrr INFO
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BLDG ELECT PLUMB MECH
. LICENSED CONTRACTORS DECLARATION
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Job Description -
1 Wrathy affirm Net 1 m littnsed under pmvlai�9i of CTaPmc9 (wmmeneing
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with Smfim] of Di on Sol NC BusimaaaM (tjsil mom Code,m ylicenmh
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immfifmuean em
REVISION--IN HOUSE USE ONLY -
Liceoo C Lick
Dara contractor
NO NEW..PERMIT ISSUED/ORIG.- #04080T73 - _--'-
ARCHITF.CI'S DEC
luddc m plaits shall pub
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Lcensed Pouf -
OW NER-BUIMER DECLARATION
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I hereby affirm that l am exempt tram the Con i smors License Law for the
following reason. (Section 7331.5, Business and limitations Code: Any city or County
which ".I. A Panel[ m mnsuoex. alter, improve. demolah, At -pail Any =me-
prior to its unciame, also requion, Ne applicant forsuch Permit to file a signed summers
that he ie licensed Puiwam wins provisions d Ne C.Mrector's U.. LAA, (Chapter 9
Sq. Ft. Floor Area
Valuation$43'.
(commencing with Section 7303)of Division 3 of Na Busioaaand Profoaians Caw)or
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Met he is exempt therefrom and the more fm the alleged tumptim. My violalfon of
APN Number
Occupancy Type
Section 7031.5 by any applicant far a permit subjects the applicant in a civil penalty of
Inst mac Nov Ove dmMed daltsrs (f500).
369,40017. 00
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❑I.As ower orthe property, Ormymployemwith =gas ntnehwlecampensation,
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uired Inspections --� -
Mildathewark,andWswctumisnotlnmdedma@redforeek(Sec.R)N,BusirsuqRe
and Ptofauions Code: The Conmcwes License law data set Apply b M owner of
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propanywho builds mimpwmtherwn,mdwhodoesauch work himselfor through his___-_--
own employme. provided that each improvements Art notinuMrd oroffered formula. if.
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however, the building or improvement lateral within am year of mmpletim, the owns-
builder will have the burden of Moving Wt he did not build or Improve for purpose of-
u a.1,
❑ I, u t Me p of the property, m =elusively nd contrasting with ) TheeCommuwn U.
construct jot (Sec. And Codes lbs Coni... W-
/
\
wbo ui improves sed,
whoa law dao not apply w ts owner alpmpeny who
des n .. own. of property
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sed Mum Conran.
whocontractsLa ufor such projects with ernnumtar(s)Ilanud punuwiwlhe Contractor'sLicense
law.
❑ I em exempt under See.' - . B k P C to, this rause
\
Owrer Dau-V\
WORKER'S COMPENSATION DECLARATION
I Mmby dorm under penalty of perjury om of the following decim3mu:
I haw l of u for Woakeb Ce
3mm
of Me
o! Nc Labra Code. for Ne perfarmeme of Ne
prOvid for by SectionMe Labor de. far
Asa.r provided forma Section
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d.
wok for which this pemrit is issued.
❑ 1 have and will malntsin Worker's CampenemAn I.Cc, u required by Section
3]30 of Ne labor COCA. Me performance of Ne work for which Nis permit is mixed.
My Works Campen on Inner ms canis iry nu ber a
C ' UwYN0.: G
CE (FICA OFEXEMP1T0 0 KERS'
,
COMPENSATION INSURANCE
Tbisuctim Amid notWcanpleted ifthe Permit is foram hundred Oil= (SIM)
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or kai.) -
I cenify Net in Me part.. of the work far which this Permit I, ismad, I Mail oat
employ any person in any mannerao as to become subject to the Workers'Compensa on_--
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taws of California. Data
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Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption. you Amid
became subject to the Workers Compensation provisions of Ne Labs Cade, you must
forthwith Comply with each powiims or Nu pemit,hall be deemed revalued.
CONS 11UcnON LENDING AGENCY
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Ihemby.lion Nat Nem Is a conswctinn lending agency for the performance of
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the .,it fur which Mia permit U issued (See. 3097, Co. C.)
Undoes Nam.
land,es Address
1 ttnify Met 1 hew read this application and cute Mat the ,bow information A
.
cones. I agrm to comply with all city and county ordinances nd sum laws minting In
Wilding construction. and hereby wNodw rtpmaenutivev of this city In enter upon Me
avow-mentoned property for WINCU n purposes
(We) Agra 1a rave, indemnify rad keep harmless, the City of Cupertino against
liabilities, judgments. emu and ex a which may in ray way ams agunat said City
/nZle5:;)
In onaegxencc of the inning is permit. _
A CANT UNDERST A WILL COMPLY WITH ALL N-
Issued by: Date V��
SO EG TI
r/
Re-roofs
of Roof
si!nOk ofKpiiikaWcomaACtA, te
HAZARDOUS MATERIALS DISCLOSURE/Type
WIII On applicant or future bullding aeupant sure w handte hewn)ous material
u defined by the Cupertino Municipal Cade, Chapter 9.12. and the Health and Safety
ode. sada. 25532(.)7
❑tics 9ran _.
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without Errs[ obtaining an inspection, I agree to remove
WIII the applicant or froom building aeupam Use equipment or Ucvices which
it he'raNao air consminants As dunned by the Bay Arta Air Quality Management
all new materials for inspection.
District?
❑Yu �m
I have read use harardmari awri.4 requiumcw under Chapwrii.95of tie Califor-
n' HutN&Sdciy Cade.Sa =25505,25533ud255M.1undcrnand MatifNc building
t Cloi have a tenant Mat it u my responsibility in notify Ne t Me
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i e mkhmunWmetpdorwiuummof,CcnifcamafOcC Pr.
Signature of Applicant Date
All roof coverings to be Class "B" or better
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or aaN. ant w