08080150 CITY OF CUPERTINO r'`"
BUILDING DIVISION Pgjjlyfj'j' CONTRAGTOR INFOrRMATI .
BUILOI A �tEsS: PERMIT
l (�G58� N DE ANZA BLVD SOUTH BAY CONSTRUCTION CO 080800
150
lerR'S:DAME: PERMIT ISSUE DATE
7)PAJ E. ]',NC . 170 KNOWLES DR 08/20/2008
PHONE: SANITARY NO, CONTROL NO.
(408) 379-5500
ARCH=/ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION -
1 bereby affirm that 1 am li¢nsed under provisions (co
of Chapter 9 romrxing Job Description
f�E withSection?0110)ofDivision3aftheBminwmdNofe =Coda, dmylicenwu COMM' L DEMO WALLS, FLRNG,CHAIRS, FABRC WL COVRNG&
n=,� in full Tome amW effus Lr
Jaz License❑ Lk.a CBNETS
n F p Dam Contruwr
FF7W ARCHITECTS DECLARATION
C 1 understand my plans shall he used as public secures
JdU
5� n Licensed Professional
n3 OWNER-Bxemptf mDECLARATION
E I Newby.(firm Nat 11. exempt from tiro Conmctors License Itaw for the
❑O following dies a (Section]construct,
Business and r A,tide um Cade:Any city or county
K$E which rtquiwa 1 e.at.re coriarucL alter,Impmvu,h permit t,or e a sig any hnmturo -
4i< prior wiu issuana.alw roquiws the applicant for wch permit Ole xsigned summer
that Ile Alicensed ursuant wtiae rovisiam of lam Canuwwrt License Law(ChaPmr9 Sq.Ft. Floor Area Valuation
xI- (commencing with section 7000)ofMimi 3ofIll,Business and Profession,Code)ter $100000
that k is exempt ulewfrom and the baso fm that alleged!exemption.Any violation of
Section 7031.5 by any appliant for a pvmit ntepeu tae applicant w a civil penury of �pp�P Number Occupancy
not mom man 0w hundred dollars(ssud). 316 2 2 017 .W P Y Type
❑Lssownv of and
propvry,or myemntendedwithwagesatheir role cmm.ROSS n,
will do thework.and la- sWmurt is out ces License
Law doi fersxk(Su.7014,Business
and erty who
Calc:The,Coousewrs Dame does
data rot appy w an awraer,of Required Inspections
.aenywhobuildsorimpmvu Hereon,andwho lasauchwaed!offifv Nmugh his
awn employee,pwWded that web impmvumwu tae rot iear ofc oroRved faraln t-
however,thebuildinguimpmwmentg All withinet ill of wprown frtheuwmcry
Aredv will hew the buNan of Proving them he did rot build or improve for purpose of
akJ.
❑I.as ownv of th<property sm esclusi rely commuting with handed conwcws w -
consuut,the prat(Stec.7044.Business sad Profvsiom Cade:)TM Capmawr 3 U.
comiclaw does not apply w an owner of property who builds or improm daemon,and,
who concocts for such projects with aconuuloKs)licensed puranant w We Contractors
License Law.
Iamtaemptumdv See. ,B&PCforthoreawn
Dina
WORKERS COMPENSATION DECLARATION
I heteby air=under penalty of Perjury one of the fallowing decluatianh -
❑Iha.eandwillmainWi aCertlfmesmofConunuowlf-imumfor Wark sCompcn-
sation,as govided fm by Scutum 3700 of the Labor Cade.for Who pvformance of the
work for which Nis Permit is issued.
❑1 hew and will mumain Workers Compemxdon Insuraont,as mquired by Sumimn
3700 of that Labor Code,for the performance of the work for which this Permit is Wood
My Workers ompenaxtion from.carriv and Policy number m:
tinier. 'C T Policy NO: 0--i;
RCATE OF EXEMPTION MOM WORKERS
COMPENSATION INSURANCE -
(Thisscvim need not be completed Kthe permit is i.e.hundred dollars($100)
or leu)
1 cvtify that in tee performance of the work for which this Permit is issued.I shall nor
,unliterary pawn in any mannerw as to become subject tp the Wmkeri CompemWon
Iowa of California.Due
Applicant
NOTICE TO APPLICANT:If.after making this Cemrrcaw of Eumption.you should
become wbjea in de,Wmkcrs Compensation Provisions of the Labor Code.you muse
wJ O foMwith comply with wch provisimu m this permit 16111 be lamed mwkcd.
ti Vj CONSTRUCTION LENDING AGENCY
[—m I hereby llfirm last Vert o a cmASmWorn lending agency for the performance of
!Yi the work for which this Permit is issued(Sec.3087,Civ.C.)
QLenders Nurse
z funders Address
U 0 1 artily last I low nW this applkuion and sou Wt the Wow information is
II, —I correct.1 agree In comply with all city ad county oremancea and sou laws mixing in
0 Wilding conwucdon,and hereby amhoriu rtpresmudmof this city to enter upon Ne
Fhove-mentioned propcny for inspection purposes
4 a (We)agree to An.indemnify and keep harmless the City of Caperuno agumt
liabilities,Judgments,costs and cap..which may in any way ucnm xgxinstsei&in e
V z
i
n co afthogranting of this permit. '( 26 a p
AM NDERSfAND N WILL COMPLY WITH ALL/ON-POINT Issued by: Date r5
RE CATIONS.
i 3 � /� Qo/oS Re-roofs sJ
S nuuwo
Dime
HAZARDOUS MATERIALS DISCLOSURE T - v —
ype of Roof
Will Ne applicant or fume building eaupant swm or NMIe ardoa material
defined Dae Cupertino Mu io<ipal Code.Chapter 9.13,seH
d the esth se
ld Safetycty
.
Section 25532(x)7
❑Yes NAll roofs shall be inspected prior to any roofing material being installed.
WBI thea applicant or future building Occupant ase If a roof is installed without first obtainingan inspection,I agree to remove
pp g e cyuipmca or devices P
"irhmsNom air contaminants a dcfinN by Rae Bay Ana Air @Wiry Management all new materials for inspection.
lTs0iv7 P
❑Yes �No
1 have mal the hvuNws mauriaorcquiremenu underCMpus6.95of the Califor-
noHrslth Sifelycode Sectimu2M5.75533xm125536.1undmwndN if&Wild I A
>c only haw a mnan a it y my responsibility w nodfy de, Pant due Gti Lk
rtme which much the, or mssuanao Cu4ifvm a(Oc
� 8r
SighatinfofApplicant Date
owners or wthamed agent D m All roof coverings to be Class'W'or better