04040143 CITY OF CUPERTINOfSe
BUILDING DIVISION PERMIT �,'CONTRACTOR�INFORMATION 14
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BUILDING ADDRESS: SOUTH BAY CONSTRUCTION CO nITN904040143
OWNER'S NAME: PERMIT ISSUE DATE
CTC FUNDIN
r SANITARY NO. CONTROL NO.
408 379-0400
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
upp LICENSED CONTRACTOR'S DECLARATION lob Description
y Z C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing (� ��----••�ry P
<<U with 5c n] ))uf D'vision3of NC Busilc arM Professions Code,an9 mYlicense is t�gr't� II /5 ss r�
"o t'n in tun fire d cffecv �� T uVaaiii•"Jt,T`YY1(t11�V.ILII7�J1.'{
z Lie ns tic.II
—� On Contractor
ARC SDECLAys IDN
; u anacrs gyylan aryd a\puhlle records JAN Z
U. Licensed Pmf sect s I ��05
OWNER-BUILDER DECLARATIONin
Y
1 hereby rebore that I am exempt from the Conuactofs Li¢nse Law for she O
0 o following mason.(Suction](131.5.Business and Professions Code:Any city m county
$ which mtluiry a permit m conswn,elmr,improve.demolish,er repair any atmnure D L""s
prior ons issuancc.alsu ryuims the applicant for such pc.it,.Me xigned summer w
��< thal he is liccnmJ punuanue lhcpmvisinns of the Contracmr's Livcnse law(Chaptcr9 q.Ft. oo Area Valuation
FFG (commencing with Section 7000)of Division 3o the Businesand Professions Code)at
y Wt he u exempt therefrom and dma bvu for the alleged exempunn.Any violation of $157000
Section 7031.5 by arty applicant far ape.it subjects Jtc applicant m a civil penalty,of APN Number Occupancy Type
oat mon,than Eve hundred della.(S500).
❑Las owner of the pmpeuct re is employee with wages r Nei(cele compensation,
will Pr the work.ands: he Concis not:sodasm offered for side(Sec.in aa.Business
and Professions Wilds
The Convector:and
Law docs not applyhims lf an owner is Required Inspections
property who s.provided
ro o(impmvech impo and who areaouch work aroffe er through Ilia
own employee,p Wilding
or i that such imps Sold w u ase not arofintended aroeured for owner.
Iowans,the building or improsmens is sola within arc Weld of completion,the owner.
of
builder will have the burden of proving that he tlitl not build or improve fa purpose of
talc.).
❑1,as Owner of the pmpcny,am exclusively convecting with licensed contnao(s to
convect Ihr project(Sce.]oda.Business and Professions Code:)The Convacmr's Li.
cave law docs not apply m an Owner of property who builds or improve brown,and.
who contracts for such projects with a comiscusna)licensed pu.uanuo the Contractor's
License Law.
1 am exempt under Sec. .B&P C for this(cation
Owner Dam
WORKER'S COMPENSATION DECLARATION
01 hereby Stillmn under pevlty,of perjury Oro of the following dalldmims, •an and will maintain a Certificate of Consent to self-insure for Worker's Compere
,as provided for by Section 3700 of the Labor Code,for lie performance of the
for which this permit is issued.
❑I have and will maintain Worker's Compensation Wmanee,as required by Section
J700 of the Labor Cock,for the perfemmnce of the work for which this permit is issued. -
y orker's Compcnamma In..carries and Policy number are:
cr.RFAiT3LIG h�OFNIh>rfUPor :0317=1
,
_s CERTIFICATEOF�0N OM WORKERS'
COMPENSATION IN URANCE
(This Section need not Inc complied if the permit is for one hundred dollars(SI00)
or Ica)
1 certify that in Be performance of the work for which this permit is issued,I Shall not
employ any person in any manner anti In become subject o the Worker:Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,aper making this Certificate of Exemption,you should
become subject to the Worker's Compensation PIovoirmS of the labor Code,you must
wJ Z foodwith comply with such previsions or Nis permis shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
'r. 1 hereby affirm that there is a construction lending agency for the performance of
D: the work for which this pemtit is issued(Sec.3197,Civ.C.)
Lender's Name
=Z Lender's Addmas
V 0 1 amity that I have read this application and Sure that the above information 1s
L. E co((cer.I ag(a to comply with all city and county ordinances and sum laws relating to
Or, building convection.and hereby m9onno mprecnusiscs of this city m enter upon the
Uabove-mentioned propcny for inspection purposes.
(We)agree to save.indcmmfy and keep harmless the City of Cupertino againsl
rV1 liabilities.judgmcnu,costs and cxperims which may in any way same against Said City
V Z in conzquenec of the granting of this permit.
APPLI NT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by:%12� Date
SOURC REGU TION
Re-roofs
name Applicant/Con mor Dam
HAZARDOUS MATERIALS DISCLOSURE-
ISCLOSUR Type of Roof
Will the applicant Or future building occupants me or handle hldmdous mawrial
as defined by Be Cupertino Municipal Code,Chapmr 9.12,and she Health and Safety
cak.section 25532(a)? All roofs shall be inspected prior to an roofing material bei.
❑Yea �Na P P Y g g installed.
Will thea scant or future Wilding Occupant usee t or device whim If a roof is installed without first obtaining an inspection,I agree to remove
pp g p a Air n
horardous air contaminants n defined by the Bay Arca Air Quality Management all new materials for inspection.
ics?
O Yes )<No
I have mad the by rdousmamdaH requirements under Chapin(6.95 of dte Calif.,
aii Hcal &S9csy Ccdc.Sauo s05,25533md25534.lun&m=dthmirthe Wilding
does not a rally have a moa at it is my(espondibibly m muly the occupant of the
ayui(cmcmti 'ch ustbc c ' rtuissuanccoI Ccnifc aOccup ry/� Signature of Applicant Date
Zh O"1
rr or oH.d Sgrnt Dare I All roof coverings to be Class "B"or better