04120117CITY OF CUPERTINO-@7�G/^!�g'�t''a�w�a�.ra"���].fa�,«�f
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BUILDING DIVISION. _.--,PERMIT
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u>Ar�vd s.+.TL` x`rT�"i%ic. .�T' va3.Y"s.:d'+"ertl1 ,
eU1LDINGADDRESS:
SOUTH BAY CONSTRUCTION CO
ITN%4120117
10251 TORRE AVE 238
OWNER'S NAME:
PSRMITL4UEDATE - - - -^-
HUNTER PROPERTIES
511 DIVISION STREET
12/16/9,004
g;
SANITARY NO. CONTROL NO.
(408)379-0400
ARCHITECT/ENGINEER: •, -., y
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BUDDING PERMIT INFO
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BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S��LARATION
�,, af(Irm that I am IiceeN undoy f�Wmu of CMPmr 9 (mmmerall"
- Job'Description h'
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wlthSectio OfW)of Dlvi&Ian3ofthe Buai6efauW Profeulom Code. cad mylkeru°ie.
mmuf anderrem •' 9
REVISION--IN HOUSE USE ONLY
LICMe� ta u.g
Dem Can
NO NEW PERMIT ISSUED/ ORIG. #04080]:82- - •'
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Lice d fessio I - -
DECLARATION
• - OWNEon
CormION
(Rrm that 11. exempt from the Canvas
I. hereby exempt
Ucenm Law for thefollow
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. Co
Code: Any em or caunty-
(Section randy Busiws and P000ve,
roam.fourth
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demolish. structure
which • permit alter, improve, demolish. nr repair
ed
pdorbslicenadpursurequirestheapkes,ofant esuch perraft nis's ccomLw(alammhrn
poor to its !nuance. re uirest a
he Uw(Chapter9
of
limned pSectiol 7000)
-' Sq. I2L. Floor Area
•-
.. _ VahlaClOn$4,3
(cothat
roti Poi Code) err
of Division 3 an Businessland
mmencing Section 7000) f r of tbo B
exe
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Any of
tham a to and basis p ed exa on. Any
h asompt
that exempt and the bub fm the alleged cumpnt
_
_ . APN Number -
Occupancy Type _
to l pennon
atry applicant for & permit objects the applicant b a civil penalty of
io any
Section
than w
not mart than Ow hundred dollen (55004
36940.017 .00
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❑ L u owner or to property. ormy employe. with wagcass t eb sore compeneadnn.
- -
-Required Inspections u.a•
will da the wart, and thaawnurtbrmtinlended orottertd forsak (See.loN, Businm
and Professions Cade: Tho Canuacmh Litsm Law des .1 ply b an owasr of
4 . -.. .�..<,..
plenary, who bullelsor improve lhatmn,andwbodoa&tehworkhi fmthmugh his
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ownemployes.provldedmatauchimprmemenuartnminundMmaEer d(oruk.tf.
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however. the building or improvement bmld widen one your ofcempleton, the owner-
builder will now to burden of proving that k did not build or improve fes purpose of
sale.).
I, u owner of the property, am exclusively contracting with Ilcemed eonuanon to
construct the project (Se. 7000. Business and Profusions Code) The CoatroaWs U.
case Law doss not pply in an owner of property who builds or impmw thereon, end,
edp°uambNe Conus°lofa
whnconuacufarowsprojenawiNamnuanm(a) Ila"an
License Law. _
IIJJV
❑I am exempt under Sec. ,B&PC for this memo.
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Owner Dam
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WORKERS COMPENSATION DECLARATION' "' �"-'
I hereby affirm under penalty of perjury oro of the following detlaradom:.
I hawond will maintain a Certificate, of Consent to elf-Insum forWorteM1 Compel-
utlon, u provided for by Section 3700 of the Libor Cade, for ten performance of the
work for which this permit is issued.
❑ 1 haw and will maintain Workers Compensation luumhce, a required by Semon
3]00the labm CoM,for the peRarmanavork fro which
My W0d &Cam ewfon^. nrA iand and Polity number am:
a c: 11 0.:--
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ERTIFICATEOFFXEM OM WORKERS
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COMPENSATIO INSURANCE
(This .,I.. neednmhemmplemd l(the peimlt is forest, hundred dollm(61M)
at len.)
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1 coldly that In the performance of the work for which this permit is luted, I shall not
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employ any person in any scarecrow as to become subject to treWorlams' Compensation
Laws of Callfarda. Data-
Applicant
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NOTICE TO APPLICANT: IL after making this Certificate of Exemption. you should
become subject in the Workers Comecuation provisions of to tabor Code. you must
forthwith comply with such provision" or this permit shall be deemed.1sed.
CONSTRUCTION LENDING AGENCY
1 hereby effort that Vert b a convection lending agenry, for ten performuxe of
Me work fm which this permit is issued (Sec. 3091, Civ, C.)
Leaders None
tender's Add.
I coolly that 1 have read this application and sum the the &bow information is
correct. I agree to comply with all city and county ordinances and shote laws relating to
Wilding construction. and hereby wthorize representative of this city in enter upon the
above-mentioned property for inspection Porpoise.
(We) agree 10 save, indemnify and keep harmku the City of Cupertino against
Iiabllidu,judgmenu.ceuandex nseswhichm°yinmyway accmeagalmmid Chy
nuumI. anLICANT`UNDERS ung S hNof the w!.D ILL COMPLY WITH ALL N -P01
_ ISSUed by: D�
S ERG LAT
Re-roofs
of Roof
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ifft,pph oconareacuorHAZARDOUS MATERIALS DISCLOSURE \ Do,/Type
Will the applicant or form building a.vpant time orhandle balance" memrid
u defined by to Cupertino Municipal Code, Chapter 9. 12, and the Hulth and Safety
ode. Sectio" 25332(.)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yon o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant orfu tic Wilding eceupant uso oq°Ipmml ar device which
It huardau air contaminants as defined by the Bay Aura Air Quality Management
all new materials for inspection.
Mullet?
❑Yes
Ihe. mad the halardnus materials requirements underChapter 6.95 of the Califon
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I &S clycoda'Secu 525505,25533and25534.iuncnwdthulfthe building
t
cmourtly haw coo t. mal h b my rmpomlMllly m notify the scup I of
req mewkhm t etphoruthouanceofaCeolfcateofftupenc
Signature of Applicant Dale
All roof coverings to be Class "B" or better
'era
o odned agent Da