08070207 CITY OF CUPERTINO 'vim' t»? ^'�
BUILDING DIVISION PERMIT' C,ONTTtACTOR IIVI�RMATI' N_
PERMIT NO.
BUB.f]IhIG.ApII -'h DE ANZA BLVD FLR 2 & SOUTH BAY CONSTRUCTION CO 08070207
EI 'S NAME: iftfC PMITISSUE DATE
W N
APPCd INC. 170 KNOWLES DR 07/29/2008
(408) 379-5500 SANITARY NO. CONTROL NO.
ARCHnECfrENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
uoo LICENSED COTfRACTOR'S DECLARATION
C thereby"mthat 1ars licensedunder pmvuwruorChapter 9(commencing Job Description
with Section 7")o(Division 3 of da Business and Proressiov Cade.and my license is COMM'L DEMO; DEMO WLS, CPRT, CEILNG & DRS
j�Zin full force ami 336 9 7°/
Listsa Llo.N
Fq weARCHnXCI-S DECCLARAT107— .
W1 understand my plans shall W used v public records
$G Licenced Pmfclaunod
aH3 OWNER-BUILDER DECLARATION
i E I ha?
creby ne that 1 am exempt from the Contractors License Law for the,
❑O following awns.(Section 7031.5.Business and professions Cade:Any city or county
S which requires a pencil m eonBruck afar.imis owe.derad'ah,m repair my suunum
prior to is ssunaec.also requires the applicant for such permit to file a signed sutement
Sq.Ft.Floor Area Valuation
twWtsfieensed pd.IW the pnwiSi..err the Cnntr.eters License Law(ChaP=9
(commencing wits Smetkno 70DO)of Division 3 of the Bussinm and Pnereasions;Cadc)or $100000
Q`Z 2 Wt W u exempt therefrom and the basis for the alleged exemption.My violation of
Section 7031.5 by any applicant ron.permit subjects the applicant to a civil penalty of
not mom than fiw hundred dollars($500L 316 2 2 017 .ARA$Iumber Occupancy Type
I,a owns,orthe property,er my employs with wage ss theb solo compensation,
will de dim.k and Nemsemm h rot intended m afrered rmaW(Sec.I .Business
and Professions Cade:TW ComrscmYs Liana Law does oat apply to an owner or Required Inspections
property who builds m ire proves therm..and wM does such work himself or duough his
awn employees,pmvidcd thatsuch improvements art not intended oroffered forsale If,
however,the Wilding on improvement is mid within one year of completion.the owser-
Wilder ,will haw the burden of proving that he did not Wild or improv for purpose of
sae.).
1,as owner of the Property.am uclusivefy connecting with licensed contractors to
construct the project(Sec.7064.Business add Professions Cade:)Th ComracmYa U. .
cove Law docs not apply to an owner of property who builds or improves demo.and
who contracts for such pmjeaa with a conuactor(s)licensed puavnt to the Contractor'
Lv-"..Law.
0 l am anmpt under See ,B&P C for thts sawn
w Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm older penalty of perjury one or the fallowing declantionx
I ham and will maintain.Continuum of Covent.self-iusumfor Worta'Compcn-
sedon,as provided for by Section 7'700 of the Inbar Code,for the performance of the
work for which this permit is issued.
❑I haw and will maintain Worker's Compevadon Insurance,as mqubod by Section
37(K).(thc1-abor Code.for the perfarmmeeof the wok for which Nu permit is issued. '
My Work�errts.�Compressor..Invrance carrier and Polity number art:
Cartier. Ia al'1K sT'IC Polity Na.: ZSR hk$3L /
OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thu motion need wt W completed if the permit islmme hundred dollars($100)
nrteas)
I astify that in the perfo,marsee of the work for which this pc.I,is issued.l shall not
employ any person in arty manner an as to Wcome subject o the Worken'Compensstion
Laws of Califomis Dat
Applicant
NOnCE TO APPLICANT:If.afar making this Certificate of Exemption,you shmW
become subject in the Worker's Compensation provisions of dte Labor Code,you must
vJ O forthwith comply with such provisinv on this permit shall be deemed rewked.
z CONSrRUCDON LENDING AOFNCY
tom+0.FIbeab affirm than thea iso coormaction Wndin ai >
the work for which Nu$ genry for the perfwmartee of
GLanders Name on"'ait u kssued(Ser.5(19'1,Civ.CJ
z Lenders Address
U Q I terrify that 1 haw read Ws application W sate Nal the show infmmaden is
tI. conum 1 agree in comply with all city and county ornmences sour sue laws rcladng to
Q Wilding construction,and hereby aumorim mp,esenutives of this city to color upon use
F aa Wve-mendoned property for inspection puryoses
(We)agree to saw,indemnify and keep harmless the City or Cupertino ageivt
py limilides,judgments,costs and expenses which may intuy way scene agalvt sued Chy
U z in cove. f the granting of this permit. //
^ APPLI NT DEONDS AN WI OMPLY WITH ALL N N-POINT Issued by:3 Date 7('L9��
SOU E RE ULATIONS. /
Re-roofs
Si um licm9Conmcmr �p t
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store orhandle haurdom material
as defined by the Cupertino Municipal Com,Chapter 9.11.and than Health and Safely
Cone,sectionzssyz(,)T All roofs shall be inspected prior to any roofing material being installed.
Yu Na
Wilt Ne. Meant or future building occupant use If a roof is installed without first obtainingan inspection,I agree to remove
pp g P equipment or mvias which P
Distric��ov air conumu u refi
minned by the,Bay Area Air Quality Management all new materials for inspection.
❑Yes a*
I ham read dl aN<wsmaariaumquiremerus mulrChapter Q9safNcCsifor-
nuHulth&Sar .Sa:das 25505,27:77 aW 2S53a, uedcwrW thin ifdc Wilding
dos moa cu IY a enam.Nu it' my pomihi m notify the occup 1 of the ✓�
,equimrnen which muse W met prior of a 'taste mice
Z Signa sere of Applicant Date
Owner or milmdred.g.ru D,a' All roof coverings to be Class'A{ 'or better