04070006CITY OF CUPERTINO
'�'' 777777777 `"
CU`l�1'cRA1.�TO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
SOUTH BAY CONSTRUCTION CO
NCIT ND04070006
OWNER'S NAME:
PERMIT MUH DATE
APP
E:
SANITARY 0. C OL NO.
ARCHI=ffiNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t�
LICENSED CONI'RACMR'S DECLARATION
Job Descri 10
ll NAL t
1 rummy am. that 1 am licensed under provisions of Chapter 9 (commencing
LJ
with Section ]BIID) of Diviaion3 of the Bminus and Prefca.iasla Co ,and ylicenm is
in roll rorte.d tot. �J �o `I
T.I. STORAGE ROOM
Liccnm Cl Lic.
NOVf� aaoo4
r
Dem Conrmtor
tat r L
ARCHOF.CI'S DECLA ATION
1 tiers J my plea shall he used a public records
BUILDING
Licensed Pr.fcasional
OWNER -BUILDER DECLARATION
1 hemby (rarm thin 11. exempt from dime ContramCo License Law for the
following moon. (Section ]113Lm Business,Star.and
.
mli Code: Any city or county
n. de m ¢pair awmuro
s a permit conmacs alto. improve, demaalts
which tas
ed
t signed shmmem
issuance. also mquirre m. applicant for ouch perms' m 01.
prior m s i u re
Sq. Ft. Floor Area
- Valuation
theofDiviomofthe C. (Chapter 9
licensed thes
Code)
(commencing with Section of Division 3 of the Cod.) ser
(comm� cngpSectio 7
alleged exempt on.fAny vl
that he is exempt thcmfrom and dao base for the alleged esemption. Any vlaladon of
830000
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant At a civil penalty of
not mom Nan rave hundred dollar
r
Q 1, an owner of the property, or my employees with wages AS their sole compeneadon,
Required Inspections
willdo the work, and theswcture Ice mtimmcded oroRered fonale (Sec. 7044, Business
and Prefessi.0 Code: The ComactoYa License Law does not apply a an owner of
who builds mimproves Herron, mdwho drses.whwork himself., through his
own employees, provided insomuch improvements as notimmnded or offered (orale. If.
however, the building or improvement is said within am year elcompletion, the nwm,-
builder will have dm burden of proving thal he did an, build m Improve for purpose of
sale.),
Q 1, as owner of the property. am exclusively contracting with licensed contractors to
construct Ne project (Sec. 7044, Business and Profusion Code:) The Contractors Lt.
come law does not apply to an owner of property who builds or improw;m daemon, and
who contacts for such projects with a contractor(S) licensed pursuant o the Cmerache s
License Law.
Q 1 am esempt under Sec. . S & P C for this mason
owner Dam
WORKER'S COMPENSATION DECLARATION
hereby alfum under penalty or perjury one of da. following declarations:
W1
'x and will maintain a Cenifiam of Consent toml6insure for Worker's Camper.
n, ds provided for by Section 37M of the Labor Code, fm the performance of the
work for which this permit is issu.d.
Q I have end will maintain Worker's Compensation Insuranm, as required by Section
3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My Work;' Comp a.tion nose earti and Policynumbcra7",7
Carrie : ��
r./ . W.cy No.: � �J i Z Z Z- / v
'
/ CERTIFICATE OF EXE ON FROM WORKERS'
,
COMPEISATI NINSURANCE
MIA Section need not he completed Rahn permit is for one hundred dollars ($IM)
or A)
1 certify that in the Performance of the work for which this permit is issued. l shall not
employ anypers.n in any manner so AS 0 become subject to the Workers' C.mpensNon
Laws .f California Dam
Applicant
NOTICE TO APPLICANT: If, after making this C omficate of Exemption, you should
become subject to the Worker's Comperesation provisions of ohs labor Code. you mum
forthwith comply with Such prevision or this permit shall be dimmed maked.
CONSTRUCTION LENDING AGENCY
I hereby am. than he. is a commsea on lending agency far the perform... of
the work for which this Permit is issued (Sec. 31197, Co. C.)
Lender's Name
Lender's Address
1 comity Nat 1 have read this application and mm that the above information IS
'
correct. I agrce to comply with all city and county ordinances and sum laws minting to
building constroction, and hereby nathorim mpresenatives of this city to order upon me
above-mentioned property for inspection purposes
(We) agree to ave, indemnify .d keep harmless the City of CoNnino against
liabilities, judgments, coats and expenses which may in anyway accrue against said City
/
in conmiumea ofEm
APPLICANT UNOMPLY WITH ALL NO -POINT
Issued by: D to
SOURCE RE ��
Re -roofs
Sig sere ofA p c. for D
HAZARDOUSMATERIALSDISCLOSURE
Type of Roof
Will tie applicant or future building occupantamm or handle haysrdoes material
AS defined by tiro Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)1All
roofs shall be inspected prior to any roofing material being installed.
❑Yea o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the apple..or furore building occupant uSe cyuip rent or devices which
havardous air conaminana de0ncd by the Bay Area Air Quality Management
all new materials for inspection.
ict?
QYcs No
t�ddh&S.r
1 have rein the mourk.a mamrialsrequiremm�ts underChepmr6.95 of dm Ce ifm.
Seo M5 , 25533.d25534.Iuadar Mih if me riding
not arc y ton de ism ms shity to nodi I t 'c p t ofme
iremcme obs rta.Sman. fac.mnam a.
Signature of Applicant Date
All roof coverings to be Class "B" or better
e
ser .r. a Dm.
DU
t4 W
cs.
�z
CITY OF CUPERTINO
x 's<'
BUILDING DIVISION PE
SOUTH BAY CONSTRUCTIO CO
Bu1-DING ADDRESS:
NCITNG04070006
OWNER'S NAME:
PERMIT ISSUE DATE
APPLE
PHONE;
SANITARYO. C OL NO,
ARCHrrE T/ENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Co*. and tpy ficensc is
in full force andett (�+ `j
T I STORAGE ROOM
ClLicense Lie. N
. . .
Date Contractor
ARCHITECTS DELLA ATTON
1 d my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for Ute
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to constnut, alter, improve. demolish, or repair any structure
prior to is issuance, also requires the applicant for such permit to rite a signed statement
that he is licensed pursuant to tM provisions of the Contractor's license Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70DO) of Division 3 of the Business and Professionscodc) or
m
that he is exempt tbemfroand the basis for the alleged exemption Any vioiatlon of
830000
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mote than five hundred dollars ((500)
r
Q 1, as owner of the property, or my employees with wages as their sole compensation.
Required Inspections
will do the wort, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code The Coatraelors License Law does not apply to an owner or
property who builds or improves thereon, and who does such wort himself or through his
own employees, provided that such improvements ate not intended or offered for sale. If.
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1. as owner of the property. am exclusively contracting with licensed contractors to
convect the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon, and ,
who conuacLs for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
.
❑ I am exempt under Sec. B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
cetion, as provided for by Section 370D of the Labor Code, for the performance of the
wort for which this permit is issued.
❑ 1 have and will maintain Workers Compensation insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
Policy number am:
Cartier- 4 No.:C
My Work, Com�COAVENSAII
FROM WORKERS
SURANCE
(ibis section need not be completed if the permit is for one hundred dollars (S 100)
or less.)
I certify that in the performance of the work for which this permit is issued. l shall not
employ any person in any manner so as to become subject to the Workers Compensation
Laws of California. Late
Applicant
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
L certify Out I have read this application and state that the above information is
con=L I agree to comply with all city and county ordinances and state laws relating to
building constriction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for Inspection purposes.
(We) agree to save. indemnify and keep harmless the City of Cupertino against
liabilities, judgments, toss and expenses which may in any way accrue against said City
`
in consegitents of the gran ' g of "L
APPLICANT U R ILL MPLY WITH All. N -PO
/
Issued by: D to
SOURCE R /y`
7
Re -roofs
Type of Roof
Si are of A p oxo
HAZARDOUS MATERIALS DISCLOSURE
VAR the applicant or future building occupant store or handle han ous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Code, sateen 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
Q Yes o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
QY¢s No
I have read the hazardous materials requirements under Chapter 6.95 of the ifor.
nisi Health&Ser( '0 255 .25533 anc125534, l andctstard Ifthc tiding
does not c y ten th is m resp ifsiblity to notify t of the
mebe r� aancc, raCenifiate L
Signature of Applicant Date
Zrcq;,nts
All roof coverings to be Class "B" or better
or au a Date