04040128 CITY OF CUPERTINO �,r
BUILDING DIVISION PIiRMI'I' CONTRAC�TaOR IN1 QRMATION x:;
BU I LUNG A DURESS: BAY VALLEY CONSTRUCTION IN,
ERMITNLb4040128
10105 DR ANZA RT,Vr)
OWNER'S NAME: PERMIT ISSUE DATE
10 COLDWELL BANKER 47 RICKENBA 20 2004
1MNE: SANITARY NO. CONTROL N0.
(925) 449-7498
ARCIIITE-C/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�U-5 LICENSED CONTRACTOR'S
nsedunerpDECLARATION
U-C I nemny afrrm mm I am licensed Bd under provisions of Chapter 9(commencing lob Description
azbw with
Sectionndaiior Division]ofJtcBusinc<aand Professions Code.and myliccnsc is
n« Lrfull a,mrnrceanderr«t. REVISION--IN HOUSE USE ONLY
jg= License Crass Lica
,�o Dam Cmumakir NO NEW PERMIT ISSUED/ ORIG. 404030063
FY wl ARCHITECTS DECLARATION
K I 1 understand my plans shall be used as public records
a.
I,o y Licensed Professional
OWNr:R.BUILDER DECLARATION
a S I hereby affirm that 1 am exempt form the Contractor's License Law for the
p o following reason.(Section 7031.5,Business and Professions Coda:Any city or county
r m which requires a Permit to eonsruct,altar.improve,demolish.or repair any structure
L¢i prior to its issuance.also requires the applicant rot such Permian Glc a signed statement
=2p that he is licensed pursuant n the previsions of the Contractor's License Law(Chapter 9 Sq, Ft. Floor Area Valuation 0
yF
(commencing with Section 710()of Division 3 of the Business and Professions Chdr)or
i That he is exempt mcmfrom 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 ane APN Number Occupancy Type
not more man Ilion hundred dollars(s50dk P Y YP
❑L as owner rnn<vrrperty,m my<mplrye<a wits wages at theb am<ermpennllrn, 35909017 . 00
will do the work,and the soucmte is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law doer not apply to an owner of Required Inspections
property who builds or improves ther<ontand who dues 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 you of completion.the owner.
builder will hays the burden or proving that he did not build or improve for purpose of
We). C</
1,as owner of the property,am exclusively contracting with licensed contractors m v
cnnatrrct the project(Sec.7044,Business and Professions Cuda:)The Contractor's Li. (�
cense Law docs not apply toin owner or property who Wilds or improvesthermar,ac and. V
who contracts for such projects with a comnnor(s)licensed d pursuantn me Conoaarh
License Law.
❑Ivo ea pl Mr Scc. ,B&PC for this reason
Z Date —lei .OL
WORKER'S COMPENSATIOND RATION
I hereby affirm under Penalty of perjuryone th owing declarations:
❑1 have and will maintain a Certificate of Consent to s<If-insure for Worleer's Coni
nation,as provided for by Section 3700 of the labor Code,far 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 Ne labor Code,for he parfm a nce of the work for which this permit is issued
My Winalker'l Coql,eirannn Insurance carrier and Policy number am: 'T
Co - t 'cy NO.: CLtG�017!. (
CERTIFICAT OFEXE NFROM WORKERS' BIII/
CCC- _ C✓LtQ //.0/ta�OK�EN5AT1 N INSURANCE
rrhix meow Decd not nae repleted i(the fefmit is ler one hundred dollars(SI 0
nr
leas.)
1 Certify that in the performance of the work for which this perm's is Issuad.I shall not
employ any person in any manner sr.as Or heoumc subject m the Woderi Compensation
Laws of California.Data
Applicant
NOTICET'O APPLICANT.If.after making this Canines.of Exemption,you should
heroine subject to the Worker a ComP<nsarrin provisions of the labor Cole,you must
�z forthwith comply with such Provisions m this permit shall M daamcd revoked.
z CONSI'RUCPION LENDING AGENCY
j-+ I hereby alarm mmmcre is a construction lending agency line he performance of
the work for which this permit is issued(Sac.3(197.Civ.C.)
[g)Q Lander'a Name
z Lander's Address
J C 1 certify that 1 have read this application and state that the above information is
Pcorrect.1 agree to Comply with all city and county Ordinances and Stam laws relating to
0U building construction.and hereby authorise representatives of this city to carer upon the
r a above-(We) ed I.porysave formarathonPurposes.
(We,)agree m sass,indemnify es keep harmless ma City or against
idCtagainst
HN inconiequenc of theoaring Of this expenses which tory in anyway accrue against said City
U z A APPLICANT
of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC RE ULATION�
20ta Re-roofs
nature of Appllcant/Cmunu m Date,
HAZARDOUS MATERIAL ISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle bmarduus material
as defined by the Crpenino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Section 25532(x)?
it ❑v<a r�NO All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building by the D tau equipment or Maas which
mit District' us air mnmminanu u Jenne)by the Ray Arca Air Quality Management all new materials for inspection.
Uisoict?
❑Yes No
I have read the havaNnus materials mquiremene;under Chapter 6.95 of the Califon
nice Health K Safety Code,,Sections 25515,15533 and 25534.1 undersund thin if the building
dots not currently have a tenant,that it is my resrymsiolitr Ir nnmy Ilia occurrent Of the
mgrimmcnum� mmustbehampsoanlasuanceofacan,fico rrCoCuanay. Signature of Applicant Date
y r authori.cJ gent part
All roof coverings to be Class"B"or better
a