04120113CITY OF CUPERTINO
M•+ks., •.. R✓3. A iu^m 4, ''i ,* d'. yi.•.,'iu58':r:
?gym ,�',�{
-
BUILDING DIVISION' _ PERMIT -
Q''�
�v0�kACT0 .L1, Yx
BUILDING ADDRESS:
SOUTH BAY CONSTRUCTION CO
IPJdIT N904120113"
LVl
10251' T
OWNER'S NAME:
-
PERMITLSSIIBDATE
HUNTER PROPERTIES
511 DIVTSTON STREET
'_2_�90_24
E:
SANITARY NO. CONTROL NO.
(408)379-0400
ARCHrMCr ENGINEER:
-
BUILDING PERMIT INFO
eLDGO ELECTO PLO MECH
' LICENSED CONTRACTORS DECLA no"
" W But 1 sen licensed under proviilo f Cl Y Iso
I Me licnBd umler to
Job Description
P
1i.lg
wlNSection] of DlvW MCOO. ylkenmB
OO.
infull f eHdn ? (o'%
REVISION --IN HOUSE USE ONLY
Dae Contrscm
NO NEW PERMIT ISSUED/ ORIG. #04080177 -
ARCHntcrs DEcla
.1 undo , dl h moil as public
- ..
Licensed PmR n
OWNER -BUILDER DECLARATION
"
I hereby arorm NN i am exempt form de Contractors Ucenm Law for the
- -
following won. (Section 70314 Bminess and Rofeuiom Code: My city or county
which mquhu • ppmit to mMOMMI, ager, Improve, demolish, or repair my nmcture
- -
prim toits istuanea, alw requires Ne,pplkam forms permit m file a signed mamment
he is named Contractor's Uanm law tchlpme 9
Sq. Ft. Floor Area
Valuatlon$43 --
that pursumd mdse provismmofae
ti Proons Code) o,
(commencing with Section 7000) of Division 3 ofdhe Business ankui
- ...
_
-
dust he Is exempt therefrom and the buil fm Oe alleged exemption. My violation of
APN Number
- Occupancy Type -
Session 7031.5 by any applicant for a permit subjects Lou applicant m a civil intensity of
not mem than five hundred doll. ($500).
36940017.00
❑ 1, ss ownm of the pmpeny, m my employm with w,gu u ftir mleampmssdon.
.. ' '-. Inspections
Required Ins
winds Newmk, mdthe,wcturclnod intended oroBercdfmNe(Sec.70H, Busineu.
sold Profeashu Cc&: The Commences Liaise Law dots ort apply m an owner of
q P
propenywhe buildlerimprowthercan. and who deessuch work himselforthrough his
-
own employees, provided NW such improvements sae no intended oro@red for sale. If,
however, the building or Improvement Is mid within one Seca of completion. Ne owner•
.. _
-
Wilder will have the burden of proving than he did not Wild m Improve for purpose of
- -
sale.).
❑ I, u owner of the pee, 704 ,m sines and convening with licens:)119 Cmnuacton t.
consimct the project (Sec; Business and m Cade:) The
- ..
- Jv
who s themm'.
tau not apply ro m owner of property who Wilds or Improves demon, and,
o an property
cerds,who
M•; _ ,
whenceLfor such projects wlNeconummr(q licensed punuendto Ore Conuxtah
contracts
- -
Lice
❑lamexemptunderSec. ,B&PCfor Ni, won
our ' Dam
_
^" 1�^-"r'•*' -
- WORKER'S COMPENSATION DECLARATION ,..--"''""""'
I hertb-a07rm under nalt of u one of the following dedwfloru:-
Y Pc Y Perj 7 $
- -... ..
Ihave and will ..low!. a ceNOcato of Covent to selFimune for Wmkees Compete
-• -- .- .. •.
Winn, ss provided for by Section 3700 of du, Labor Code, for the performance of the
'
work fm which Nis permit iv issued.
❑ I have and will maintain Workers Compensation Insurance, u required by Section
POO of the rCode, for Ne perfommce of Ne work fm which thin permit is issued.
My We mincers Insu.nce nnictpr Policy nu.W arc:
,
Cartier, N
- FTCATE EMPfIFRO W ERS'
COMPENSATION INSURANCE`
" essectlon need no, Wcompleted Hand pertnh 1, formsobludmddollm($100)
-
or IM)
1 unify that in the Performance of the work for which Ida permit is issued. l ,hall not
employ anypesmn in my mumto as to become subject in the WorkoK Compensation
Laws of C,lifomiL Dam
Applicant
- ..
NOTICE TO APPLICANT: If, after making this Certincate of Exemption. you should
become subject in the WoduYs Compensation Provisions of the Lahr Code. you must
forthwith amply with such provisions Or thl Permit mail be deemed evoked.
CONSTRUCTION LENDING AGENCY
"
1 bereby aRum Nat them is a anstorcdon lending agency for the performance of
,be wort for which this Permit Is issued (sec. 3097. Civ, e.)
Lenders Name
_i•l
-/-'
Aow
Lender'sll
un l
I agree then I hive read this and some Nat ahve information
ocho
cortem 14rce ec comply with all sly toil ceumy ordlnsnm and scam law relating m
city and county and
\
Wilding entioned amend thereby authorm, rposes vex of this city toanter upon the
//
for inspectionniakeeha
lhvC(We) S. to keep harmless 0e City of
(We) agree to cove• indemnify d
accrue City
es mar in mY war anerOc agsomt Sold Cily
liabilities.Judgmenu.costs andO"
Ast
'AMa "'which
nPPLI a Of he grIT anti DS IND WILL COMPLY WITH AL NO DINT
0
Issued by:
SOURCE O
Re -roofs
Type of Roof
Si ere of ApplicanuCenuactor I Date
HAZARDOUS MATERIALS DISCLOSU E
Will the applicant or future building eccupmd mom or handle huafdom material
an defiled by the Cupenino Municipal Code. Chapter 9.12. and the HcaIN and Safety
Mae. Section u532(.)7
❑Yen
All roofs shall be inspected prior to any roofing material being installed.
CO.
If a roof is installed without first obtaining an inspection,.I agree to remove
Will Ne applicant or fudum Wilding Occupant use equipment or devices which
It Imeardnus air contaminants as dcnned by the Bay Arca Air Quality Management
all new materials for inspection.
DimieR ,(f�
❑ Yes
I have mad the WaafdOna mated smqulm-nu uoderChapm6.95ofthc C.Rfmr
lie Ndk safctyCode,9ectio 25 5,25 3.d25531.1 undemundthmiftho W' ing
dors sly ha a to n. his y rcspomlM1llhy m notify de cup of Ne
mqulm I em or ssuaneeeflcconcam _cY
Signature of Applicant Date
roof coverings to be Class "B" or better
o
r or auto. lea seem Dole