07090062 CITE'OF CUPERTINO
BUILDING DIVISION PERMITd��ITAQ�2
PERMIT NO.
BUILDt�VTSIZ SSRIDGEVIEW CT 2ND FLR SOUTH BAY CONSTRUCTION CO 07090062
l(J
':R'S NAA 7 ME:: PERMIT ISSUE DATE
APPLE 170 KNOWLES DR 09/18/2007
PHONE: SANITARY NO. CONTROL NO.
(408) 37 �-550C''
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
p LICENSED CONTRACTOR'S DECLARATION Job Description
LU 1 bereby affirm that I am licensed under provisions of Chapter 9(commencing
:Z� withSccaon7000)�lv
BusincssandProfcssionsCodc,andmyliccnscis T. I -NEW WALLS,DOORS, SIDELIGHTS,REVISE (E)
I',a in full force and eff
z License lasLic.B u,t ,7 IfCEILING GRIDS r NEW LIIGHTNG r HVAC & FIVE SPRINKLER
Datc CTSDConECL RATION LAYOUTS. NON STRUCTURAL INCLUDES ELECT,MECH
I a< I understand my plans shall be used as public records
raV
U.y Licensed Professional
n 1
OWNER-BUILDER DECLARATION
� 1 hereby affirm that I am czcmQt from the Contractor's License Law for the
jp O following reason.(Section 7031.5,Business and Professions Code:Any city or county
Pi which requires a permit to construct,alter.improve,demolish,or repair any structure
?i r prior to its issuance,also requires the applicant for such permit to rile a signal statement t'q.Ft.Floor Area Valuation
-_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 t
t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $528160
e.
.. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type
not more than five hundred dollars(5500). 31606 04 5
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are 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.).
❑I.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
.r Date
WORKER'S COMPENSATION DECLARATION
I hereby arm under penalty of perjury one of the following declarations:
C]I have and wffiill maintain a Certificate of Consent to self-insurc for Workces Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compee1nsatioon.I'n'sure cc carrier and Policy number are: 2
Cartier: %1 - �'T`f 7^ 'US Policy No.: b-31
CEOFIETE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z t'' CONSTRUCTION LENDING AGENCY
(~r to I hereby affirm that there is a construction lending agency for the performancc of
GY.> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az l'ender's Address
U 0 t certify that I have read this application and state that the above information is
cortcct.I agree to comply with all city and county ordinances and state laws relating to
C J building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
�. APPLI UNDERSTANDS AN W1LVz
WITH ALL N -PAINT Issued by:
SOU CE ULATIONS. � 0
Re-roofs
sig urc of plicant/Contractor Dare Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle harrrdous material
�c defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Ic,Section 25532(a)? '�[/ All roofs ;hall be inspected prior to any roofing material being installed.
❑Yes pU No
— 6
///�\\ If a roof i;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 as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
1 have mad the de,Sectio materials requirements under Chapter Lha i f dtc Califor-
nia
__I - �—
nia Health&Safety Code,Sections 25505,255"d 25534.1 understand lhatiCthe building �
docs not rtcntiy have a tenantRlhtsi m{re(sd.onsthilil notify the occupant of there tri cnL hich must be meee c of occupan Signature of ApplicantDate
q All roof coverings to be Class "B"or better
Owner or authorized agent Date