04120120CITY OF CUPERTINO
',PERMIT.' --t
R INEIV�111Y
BUILDING DIVISION
W� )RA
BUILDING ADDRESS:.
ITNfb4120120- -
SOUTH BAY CONSTRUCTION CO
10251 TORRE AVE 4f 160
OWNER'S NAME:
PERMrr MS 0DAT8 .... .•.. — _ -.. .. :...
Sibia
TIP ALAVI
511 DIVISIO
E: -
SANITARY NO. CONTROL N0:
(408)379-0400
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ARCHITECTIENGINEER:
BUILDING PERMIT INFO
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BLDO ELECT PLUMB MECH
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- LICENSED CONTRACTOR'S DECLARATION
' - Job Description
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I hart res Wt 1 un IkernN under powiiaio of Chat w 9 (ce anufnat
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withSection of DlWeian SoflW BueinwandP elan Code, and�y,�fceno is
inmuraR her �7 T
REVISION --IN HOUSE USE ONLY
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NO NEW PERMIT ISSUED/ORIG.#04090233
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� CHITF.CI'S DEC TION
I aelhall he useAupuN r gprN
OWNER -BUILDER DECLARATION
I hereby affirm I bre exempt from the ContrariesLaw for the
My
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following aeon. (Section 703 1.5. Business and Rofessiuu Code: city Or county
Jar. improve, demolish.
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which mquirm a pormil to construct, a repair my struclum
prim m its WoMOCC. alxu requires the applicant forsuch permit to file asigred statement
is de Conuvctore License iaw(Chapter 9
Sq. Ft. Floor Area
Valuation`
-43
that he licensed pureugnt to the provision of
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(commencing with Section 7000)ef Division 3 of the Business and Profusion Code) or
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Nal he Is ¢¢crem pt Iherefuand the basis fee the alleged exemption. Any violadon of
- APN Number ..
- Occupancy Type -
Section 7031.5 by my applicant fw a permit subj on, the applicant a a civil penalty of
nm mote than ftw hundred dollen ($500).
36940017.00
0 T. u awnm of the pmpmy. m my empkycas with wtu u theUuk eampenssdbn.
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Required Inspections
.will do the work, and the structure imothawad oroBerel Forma (Sec. 70th, Business
and Prefesalon Code: The Canlruwrt License Law dw.lwl apply In an owner of
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property who bWldaawmprowathereon. and whodouauch Work Mmaelforthrough his
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ownemplaycca. provided Nuauch improwmenu¢rent intended moRered formic, If,
however. Ne Wilding or improwmem is suldwitin can you ofempktion. the cannot.
builder Will have the Wnscn of proving that he Bid not build or improve for purpose of
sate).
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d com ant
❑ 1, u ower of ser exclusively cneacling with licensed comments .
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ct SeemProperty.
the project (Sec. Ota. Business and Rofnalons Code:) The U.
and
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¢lie law does not apply man owner of properly who Wilda orimprows meteon, red,
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anhocenmcu(m such projecu wimaconuxearts)Ileollsedpursumlathe Contruah
Licosa
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❑lam eCC exempt under sec. .BiPCfar mis moon
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Owner -' Dim—
)weate
WORKER'S COMPENSATION DECLARATION,_.: -...
I hereby affirm under penalty o(pedury oleofinefollmingdeclaa0on:
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Ihawandwillmaintam CeNficamaf Conmm oulf-nure fmWerkers Compen-
as0an, u provided fm by Section 3700 of me Woe Code, for the perfarmana of Ih
work for which mite permit is issued. ... ...
❑ 1 Mw and will maintain Workers Compensation Insurance, u required by Section
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371 of 'Labor Code, For to performance of to work Far which ads pemlitls awed.
My W e d Policy number me:
W.IwyN • ILL
�COMPENSA'nO
..
ON WORKERS'
NSURANCE
(1Nssttton need mi be completed if the permit B faon hundred dollars FS 100)
Of leas.)
I comity that In we performance of me work for which this permit is issued, l shall not
employ any person in my mumrm as to Weermesubject a the Workera Campewum
Laws of Califomia. Date
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Applicant
NOTICE TO APPLICANT: If, after making this Ccnificam of Exemption. you should
become subject to the Workcri Compcnmtion provisions of the labor Cock, you man
Oforthwith
mmP1Y With such pmviainn or thk permit shell W deemed revoked.
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CONSTRUCTION LENDING AGENCY -
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Ibor thi Nemeth kacd(Soc.mknding agemy res me perfamws of
.moi
Which
to work for which this permit is issued (Sec. IDBi, Civ. Cd
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lander, Name
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Lender's Addrom
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1 certify that I haw mad this application tad sue Wt the mon information i,
Comm. I agree a comply with all city and cmnty ordinances; and sok laws mating a
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building construction. and hereby Caboose representatives of this city to toter upon me
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above-mentioned property for inspection purpose,.
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(We) agree a mw, indemnity and keep harmless the City of Cupertino against
ilidelaes,judgments. core and expenses which may in my Way acme against mid City
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in consequence of the growing of this permit.
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ICA U NOS AND WILL COMPLY WITH ALL ON- NT
I$SUed by: I Date I
S00 i TIONS.
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Re -roofs
S of HAZARDOUS
AZA AppliaRDDOO D
HAZAUS MATERIALS DISCLOSURE
Type Of ROOF
Will to applicant or future care orus
and
as donned by me Cupertino Munitlpal Cade. Cnspter 9.11, and the HcJth tad Safety
MunicipalCo k, Chapter and t. Health
ode. section 25531(e)7
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will be applicant or future building Occupant use equipment Of device which
it buardnus air..romnamis u de0md by the Bay Arta Air Quality Management
all new materials for inspection.
Dlctrict9
❑Yes t3Re-
I hmc mal the hacash.ns materiaia mquimmenm under Chapwrd.95of the Califor-
nia lkelth@ SJclyCode. Swdow25505,25533 sed 25534.1 a sicamne ft ifmc Wilding
oOIL rely we tau et i 'a my mxpondhility m notl'y the pool f the
lequhe h' noun imaan«anc<mncakaf m
Signature of Applicant Date
All roof coverings to be Class "B" or better
2weef"Ofirdthorized agent