05090195 CITY OF CUPERTINOx> w �
BUILDING DIVISION PERMIT ' GONTRACTnR INFORMATION .
r
DING ADDRESS: SOUTH BAY CONSTRUCTION CO fRffNO-05090195
40ER'S NAME: .PERMIT ISSUE DATE
DADE BOHRING 511 DIVISION STREET 09/28/2005
E: SANITARY NO, CONTROL NO.
(408) 379-0400
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG EIBCT PLUMB MECH
�Op LICENSED CONTRACTOR'S DE(ILARATION
!� I on70 affirm Net I am licemcd under and!
Proom of Chopter 9(commencing Job Description
with Section 7IXI))of Division 3 of d¢Business ache Profcuinm Code.and my license is
nin mmllonamdeffea REVISION--RECONFIG. . OF ACCESS . PARKING
j n z License Class Lic.N
Dam Contractor SPACES
F8 ARCHITECrS DECLARATION
as 1 undcrwad my Plans shall W mind.,.bit, on,&
pain
Licensed Professional
g OWNER-BUILDER DECLARATION
a� 1 herehy affirm Nat 1 am exempt from Ne Contractors License Law for the
tOO following meson.(Secuun 7131.5,Business and Proicmions Code:Any city or county
5$ which retainer a Permit ms construct.a@r,improve,demolish.or repair any smuctum
prior in its issuance,also requires the applicant for such Permit o file a signed statement
m< that he is licensed purgarl to the previsions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation $0
zl-O (commencing with Section 7000)of Division 3 of NC Dart. it Professions Calc)or
y $ Nat In is exempt t homfmm and the bum for the idegcd exemption.My violation of
Section 7031.5 by 4,applicant for a permit subjects On applkant to a civil penalty of APN Number Occupancy Type
not mom Our fiw hundred dollars(M). 31622018 . 00
p y yp
❑1,as owner of the property,ser my cmployces with wages as their sole compensation,
will do the work,end die amunum is not intended or offered for fele(Sac.7014,Butd .
and Pmfessiaee Cum:The Communes License law does trot appy m an owner of Required Inspections
property who builds or improves thereon,and who does suchworkhimaclf orthmugh his
own employees.provided that such improvements ue not intended oro@red fm Ne.If.
however,Ne building or improvement is sold within one year of ampIction,the tw ner-
builder will have On burden of proving Nat he did not Wild or improve for purpose of
sale.).
❑1,a owner of sip propcny,w exclusively contracting with licensed anu gums to ) r
construct Ne project(Sec.7044,Business and Professions Cade:)The Contractor's Li. l �\
terve Law does not apply to an owner of property who Wilds or improves the an,and
hoConmmas for such projects with a contractor(s)licensed pursumm in the Contnemrs VV
Li ansa Law.
Ism exempt under See .B A P C far this
VVVVVV er Date
WORKER'S COMPENSATION DECLARATION
1 hereby aRnn under penalty of perjury one of the following deduuions:
Law and will maintain a ContOate of Consent m self-insure for WmkersCompim-
snion,u provided for by Section 3700 of one labor Code.for Ne performance of the
work for which Nis permit is issued.
Q I have and will maintain Workers Compensation I...u mquirod by Section
"I of me Labor Code,for the performance of the work forwhich Nis permit is issued.
'Y'arkcr's Compensation Immne,anicr and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he complcmd if the permit is fmonchundmd dollars(SI W)
or Ices.)
1 certify Not in On pefformame or the work for which this Permit is issund,1 shall our
employ any ninanym r19 t rreubjauo the Wnrkers'Compcaughn
Laws ofcala a.
Applicant t\
NGTICE APPLICANT#lMine making this Contrition of Exemption,you suld
become jai in me Worker's Compensation pmvisiom of On labor Can.you mug
Oz roMwith comply with such provision or this Permit shall W deemed revoked.
Z'rA CONSTRUCTION LENDING AGENCY
(—i Ihereby affirm Nat Nem is a construction lending agency l'nr the ferfurmence of
!Y
he work for which Nu permit is issued(Sec.3097,Civ.C.)
Cfences Name
D z Lenders Address
U C) I aniry that I have read this application and sum Nu the move informatiun u
LL.FConcca I Agra or comply With all city and county ordinances and stam laws relining to
0U Wilding construction,and hereby godorim rcpraonutivea of Nis city to enter upon Ne
Uj aWw-mcnuoxd propertycosts
land ex,Impaction purpowhich ms
sty (We)agree to save,indemnify and keep harmless the City or Cupertino against
in
f theCVasang eapcmesmay In any way ucrve against said City
Uz A APPLICANT
UNDERSTANDS
of this Permit.
^' APPI]CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULAnpSS. 05
�gna�mrc of�Apphca( nor Date Re-roofs
RDOUS MATERIALS DISCLOSURE Type of Roof
Will,
them
e appliant or future building occupant smm or W ttdlc huardaus material
u dcfincd by the Cupeninn Municipal Coda Chapter 9.13.and the Health and Safety
e.Section 25533(a)? ,/ All roofs shall be inspected prior to any roofing material being installed.
❑Yes CNV
Will to applicant o future building acupant u¢eyuipmcnt err lcvim which If a roof is installed without first obtaining an inspection,I agree to remove
hdvardnu air conumim us u dcfincd by the Bay Area Air Quality Mamgemem all new materials for inspection.
District?
❑Yes HNu
I have mad the hawaNtmts mamrials requirements unlcr Chapter 6.95 oldie Califor-
nia imul"SafctYCode.Sections 75505.25533 and 25534.1 undersand matif me Wilding
loos cwmndy hew a¢nam. at it 4 my capan ibility m notify be OcaPNt Of the
myuircm new ich mug to I or m issuanccrra Ccnifman,a(Occupancy S ignature of Applicant Date
Zr All roof coverings to be Class"B"or better