04120119CITY OF CUPERTINO
BUILDING DIVISION - PERT
BUILDING ADDRESS: -
SOUTH BAY CONSTRUCTION CO
ITN%4120119 '
10251 TORRE AVE 4 118
OWNER'S NAME:
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PERMIT Iffile DATE .._. '-••....
UNTER•.PROPERTY
511 DIVISION qTRRPT
04
g; (
SANITARY N0. CONTROL NO.
(408)379-0400
ARCHIIECDPNGINEER:
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- BUILDING PERMIT INFO
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BLDG ELECT'PLUMB. MECH
- LICENSED CONTRACIOR9 DECLARATION
' 1 9 �f ill that 1 sm II¢nvcd unde�pmyhioru of CNp¢r 9 (commendn{
wide Sutian] fDlWslon 3af tite Butl ofew Code mdrnylic nab'-
lob Descri tion -
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demRmrtrealkercecL—y �p�'/
REVISION=-IN HOUSE USE ONLY
Llanwcluk' "Lk.«
Dam Cont)c
NO NEW'PERMIT'ISSUED'/ ORIG.'#04100090'"" .- —
R H Cr EC
lander_- a per rec
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Licensed Prof KK
LIN
' ER-BUILDER DECLARATION-
I hereby affirm that 1 em eumpt from the Conuaclors License Law for tic
fallowing reason. (Section 7001.5, Business and Professions Code: Any city or county
which requires a permit to construct, alma. improve, drmalbh, m repair my atnmum
.which requires
its issuance. alm requires the applicant for such Permit to file asigned statement
Ito lie is licensed pursuant Rte provision_ of the Commuteslis<nu Law (Chapter 9
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., Sq. Ft. Floor Area,.
c. ^ , .Valuation
i $43.:.
(commencing with Section 7")of Division 3 of the Business and Professions Code)or
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that he N attemptdhcofrom and dei bub for the alleged eumpdon. Anyviab0on of
APN Number
Occupancy e - -
P Y TyP
Section 7031.5 by arty applicant for a Permit mb*m the applicant to a civil penalty of
am mac than n (3
five hundred dolle5007.
36940017.00
❑I;u_wireorumltrapasty,amyempwyawwwegp_mwelrmmcanpe don.
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Required IBSPCCt10OS�
willdo Nework.and Nawunaml_Imti man a roffertdmranle(Sec.706/.BuUte--
and Prorealoos CoThe Commu mrs Liceme Law don MI apply in an Owner Of
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propenywWbuilMaimprow-the.,.dwhodaeaembvmrkhi.ifatlwu{hhb
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own employees. provided that such improvements art rationaled aoffered forale if.
however, me building or imprawmml Is said within on year ofcompleuan, the meet
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builder will love dee burden of proving mel he did not Wild or Improve for purpose of
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1, u owner of the property, am exclusively contracting with licensed contractors a
Code:)Contractors LI
cpmiroa the project (Sec. ]Oen, Buainw and Pr os Cade.)
mut law dao not apply man owner of ;and
who Wilds pro thereon, and-
ry, who
whoconuectsfoauchpmjecs with ammur2anaW licensed ponuanl in me Cormsela's
License Law.
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❑ I am exempt under See. .B&PCIorthismaann
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Owner Data
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WORKERSCOMPENSATIONDECLARATION_-__ ___�-
1 hemby aeon under penalty of perjury one of me following dmlantlons:-
Ihave and willmainWnaCenlOcamafConsent m aeff-humne for Worker_ Comport.
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setmn, u provided for by Section 37W of the IaWr Code; for the perfamuae of to
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work for which this permit is issued. -
❑ I love and will maintain Worker's Compensation hasamce, as, required by Section
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3700 of the labor Codc. fa the performance of the work for which this permit is iuuW._
My Workers peosaso Itmurmm eamim and Policy p Wr a
C 1 Pdlgt,I3p R'--
ERr3�r�
O RKFRS'
C FlCATE OFCOMPE COMPENSATION
COMPENSATION INSURANCE
(This sectianneedmi he completed ifine permit Is form hundreddollaa(SIM)
Or lea.)
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1 century met In ret performaae of me work for which this permit Is issued. l shall net
employ any person in my manner an an m became subject to the Wadtnri Compensation
Laws of Celifamia. Dam
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Applicant
NOTICE TO APPLICANT. If, after making Ihb Ccmfium of Exemption. you should
become subject in me Worker's Compemation provisions of the Labe Cade, you mill
foMwim comply with such provision or this permit shall W dcemW rooked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that mere is a comuuctinn lending agency for the performance of
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the work for which this permit b issued (Sm. 3097, Civ. C.)
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Leader', Name
Lender's Address
I certify that I have read this application and tote that the above information Is
correct. I agree m comply wide all city and county ordinance- and satem laws relating
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Wilding convection, and hereby suthadm representatives of this city m enter upon the
shove-mentioned property for Inspection purposes
(We) agr e to ave, indemnify and keep harmless tic City of Cupertino so=
owhich may in my way accrue against said City
liabilities, Judgmma costs and expeaa
m tonaquence of the gMdn of s permit.
AP Nr UNDERST AND WILL COMPLY WITH ALL NO -P01
Issued by: Date
SOU0. G TO
Re-roofs
Type of Roof
4lr_
i{nst Ap lion omncmr 'r
HAZARDOUS ATERIALS DISCLOSURE
Will ma applicant or fmure b ding occupant stare or handle Intimations material
u MOnM by the Carpe ani p 1 COM. Chepms 9.12, and the Health and Safety
CaM, Section 35532(_)?
All roofs shall be inspected nor to an roofing material beim installed.
P P Y g
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If a roof is installed without first obtaining an inspection, I agree to remove
Will dee sppil t future Wilding Occupant uc equipment Of devices which
It Numnm air con ants u deft ed by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yrs ❑N
Ihave rem suchWmcnu unJcr Chvpmrd.95 ofOte Califor-
niaHcaW&SafctyCadd2553n,hund.L dLhaifthe Wild If
J cumantly hawponibility ie notify tiro ace pmt n e
rey ms h' rena'sCcmflcamafOccup sur
Signature of Applicant Dateow
All roof coverings to be Class "B" or better
res vndaD