05030236 CITY OF CUPEWI'INO t° '" �' `' �" �"'
BUILDING DIV] PERMIT CONTRACTOR,INIUI2MATION ;
BUILDING ADDRESS: PERMITNO.
SOUTH BAY CONSTRUCTION CO INC 05030236
BR
W NE AM PERMIT ISSUE DATE
APPIR COMPUTER 511 DIVISION STRERT
WE; SANITARY OL NO.
cl - SBS
BUILDING PERMIT INFO
ARCHITECT/ENC [EN: BLDG ELECT PLUMB MMI
u00 'LICENSED CONTRACTOR'S DECLARATION
Y �• 1 hereby Affirm mei I am licensed under provisions of Chapter 9(commencing Job Description
7, with Section 7000)of Division 3 oldie Businesaend Professio s ode.en yI cense is ^ i /�
<E in full nonce and cffc 111\s l r`` F7. l
y�z Licemc C—�Lic.N TI-OFFICES/BATHROOMS �d \.✓ �:�
^p Dam Cuntrecmr
rQ 7W ARsc1i1T[CI'S DEC
'>58� 1 radars Jm pie s htllbeu,edsA Pdb?-- rds //// ����
iSn Licensed Pmfcssional (' (�
OWNER-BUILDER DECLARATION
<E 1 hereby affirm that I am exempt from the Contractor&License Lew for the ��G t' Fl- s '�
00 following mason.(Section 703 1.5,Business and Professions Code:Any city ter county (f `�k
$� which requires n permit a construct,elle,,improve,demolish,or repair any structure V ,
prior h,its issuance,also requires the applicant for such permit to Glc a signed statement
that he is licensed pursuant to the provisions of the Comrxmr,Limme,law(Chapter 9 Sq.Ft. Floor Area Va
(commencing with Section7")of Division3 of the Business and Professions Code7or
in met be is exempt therefrom end 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 ,p ppt.�ts�.sts
not more than five hundred dollar,(SSW). 3CCTi V`�Y O0 Occupancy Type
I,AS Owner of the pmpeny,or my employees with wages AS their sole eompense0on,
will do the work,and the structure is not intended or offered for sale(See.700,Business
and Professions Code:The Contractors License law does not apply to an owner of Required Inspections
pfoNdy who builds or improves themon,and who does such work himself or through his
own employees,provided Oat such improvements are not intended or offered for sale IL
however,the building or improvement is sold within one year of completion,me owner
builder will have the burden of proving mat he did not build or improve for purpose of
sale.).
❑ I.as owner of On property,am exclusively contracting with licensed contractors to
construct the project(Sec.7W.Business and Professions Code:)The Camracmrs LI
cense law does not apply to an owner of property who builds or improves thereon.end
who contracts for Such projects with a contractor(s)licensed pursuant m No Contractors
License Lew.
0 a tae t ISAB&PCS his n
Owne Dem
WORK BR'S COMPENSATION DECLARATION
40 I hereby Afi.ander only of perjury note of the following LaNtmi.
❑1 have and will maintain a Cenifiesteof Consent m selbinsum for WorkersCompen-
sntion,AS provided for by Section 3700 of the tabor Code,for the performance of the
work for which this Permit is issued.
❑I have and will An.main Worker,CompeoNotin Imurance,as rcquircd by Section ,
3700 of one labor Code,for Ne per mint..a of the work for which this Permit is issued.
My Work e Comfit s flsm Ins7u�r�ptt eTaJrtier end Policy nu beA",Cartier: FICATE OF E%EMPI'IONYFAO ft ERS'
off
COMPENSATION INSURANCE
(This smimn need not be completed If the Permit Is for one hundred dollars(51(00
or less.)
1 certify that in the performance of the work for which this Permit is issued,l shell not
employ any permn in any manner in as to become subject mhe Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become Subject to the Worker's Compensation provisions of the Labor Crack,you must
O forthwith comply with such provisions or this Permit shall W deemed mvoked.
z " CONSTRUCTION LENDING AGENCY
I hereby AMNA mu there its comtmction lending agency(fir the performance,of
pi r7 the work for which this permit is issued(Sec.3097,Civ.C.)
WILI Q Lcndcr's Namc
.L 2 Lender's Address
U O 1 certify Nat I have read this application aAd sum din the above information is
correct.I Agree to Comply with all city and county ordimntts and sum laws relating to
0U building construction.and hereby amhorix,representatives of this city to enter upon the
r Ck1 above mentioned property for inspection purposes.
F 1 (We)agree to save,indemnify and keep harmless the City of Cupcnino against
h
liabilities,judgments.cases and capacities which may in any way Scenic against said City
of the
of
U z APPLIC
APPLICANT ERSTANDSIhis AND WILL COMPLY WITH ALL NON-POINT Issued by:9102� Date
SOURCE REGULATIONS.
Re-roofs
Signmumof ApplicaDateHAZAR
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dieap uKnor!Mune building Occupant Wore fir handle Health and
AS defined by me Cupertino Municipal Code.Chapter 9.12.and the Health end Safay
CoJe,Sa Yea 25532(a)? a All roofs shall be inspected prior to any roofing material being installed.
Yea
Will me applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil haufdous it emimn inane g&I'med by the Bay Area Air Quality Menagemcnt all new materials for inspection.
Distrito? IAF+✓"/.".
Yes
I have read the havarduus materials requirements under Chapter 6.95 of the Califor.
nix Hc.1O&S9x,,CdN.Sadons SN)5,13511 25534.Iundiralthuifthc building
d.not cu-
ly &tecta ei itumyA mibilily m nobly the eupsm the
rcyvimmemv ua mlssu af.croofic.m.fa Panty. Signature of Applicant Dale
owort ter. m cd. m d, All roof coverings to be Class "B"or better