08060021CITY OF CUPERTINO
BUILDING DMSION PERNIIT
BU1 I G RESS:
��4� N DE ANZA BLVD
SOUTH BAY CONSTRUCTION CO
PERMIT NO.
08060021
OWNER'S NAME:
PERMIT ISSUE DATE
APPLE
170 MOWLES DR
06/03/2008
PHONE:
SANITARY NO. CONTROL NO.
(408)379-5500
ARCHI'IFCr/ENC(NEER:
BUILDING PER MIT INFO
BLDG ELECT PLUMB MECH
LICENSED cONTRACPOR'S DECLARATION
Job Description
P
I hereby affirm that I am d licensed under provisions of Chapter 9 (commencing
with Section 70c1o) of Division 3 of the Business and Professions Code, and my license is
DEMO INTER WL S r C LNG S r F LR C VRNG S &DOORS (16 8 8 5 S Q )
in full force and effect 3� 7
'
LICLOEC Lie.
Dam Canlndor
ARCHi'I1rCiS DECLARA O
1 undcm nd my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the ComractOrS L)eense Law for the
following mason- (Section 7031.S, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or mesh any structure
prior to its issuance, also mquires the applicant for such permit to rile a signed statement
he is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursaam provisions
Section 7000) Division 3 the Business Professions Code)
$ 3 0 0 0 0
(commencing with of of and or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
32633114.W Number
OCCU
Occupancy TYPe
Section 7031-5 by any applicant for a permit subjects the applicant to a civil penalty of
,sit more than five hundred dollars (00()).
❑ L as owner of the property, or my employees with wages as diet sole compensation,
Required Inspections
will do the warp and the structure is not intended or offered for sale (Sec. 7044, Business
and Profession Cade: The Contractor's License Law does not applye to an owner or
9 P
property who builds or improves thereon, and who does such work himself or through his
own employers, provided that such improvements are mot inlertdM or offered for sale. If,
however, the building or improvement's sold within one year of cmnpletion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I. as Owner of the property, son exclusively contracting with licensed contactors to
construct the pmjcct (Sec. 7044, Business and Professions Code:) The Contract i's Li-
cense Law don- not apply to in Owner of property who builds or improves hereon, and ,
who contracts for such projects with a contractor(S) licensed pursuanl to the Contractor's
License Law.
❑ 1 am exempt under Sec , B R P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARAMON
I hereby affum under penally of perjury one of the following declarations
❑ h hs+e and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
salon, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which Ibis permit is issued.
❑ 1 have and will maintain Worker's Ctmtpemadon Insurance, as required by Section
3700 of the Labor Cade. for the performance of the work for which this permit is Issued
My Worke■r�s C�ompensation Insurance carrier and Policy number ate:
Carrier. r'1OCsf�Tl(� �:7+SurCV—oliry Na:
-CERTIFICATE OF EXEMPTION FROM WORKERS
/
COMPENSATION INSURANCE
(this section reed nottic completed if the perch is for one hundred dollars ($10G)
or Less)
1 certi(y that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any mamtcr so as to become subject to the Worker' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subjm to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be teemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sea San, Civ. C.)
Lender's Name
,
Lenders Address
1 certify that I have read this application and sate that the above information is
correct. I agree to comply with all city and county ordinances and sate laws relating to
building construction. 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, cosy and expenses which may in any way accrue against said City
in consequca th granting of this permit
APPLICA U STANDS AND L MPLY WITH ALL ON -POINT
Issued by: Date
SOUR EGU TfONS.
�'
Re -roofs
Signalure can ontrador Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building owupantatore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code. Scction25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yu \f�f No
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants at defined by the Bay Area Au Quality Management
all new materials for inspection.
District?
❑ Yes
1 have read the hazardous matcriais requirements under Chapter 6.95 of the Califor-
/
nia Heal h & y Co lc, Sections 25505, 33 aru125534.1 undcra and that i<the building
lll((C���l/ S
does nod men haw a tenant. iat it fs respon-sibfliry te notify the oecup � e
regriro Cots w ice must be reel erica once of a Crnircae or oemnp%
Signature App icant Date
`�' a
of
All roof coverings to be Class'.'` or better
Owner uthorizrd agent Date
_