01110072 OF
CI BUILD G DIIVISSIIONNO
NPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
1 RESULTS WAY BLD 6 SOUTHBAY CONSTRUCTION CC INC 01110072
OWNER'S NAME: APPLICATIONSU DATE
RWC, UC 511 DIVISION STREET 11/152001
/ HONE: (408) 379--0400 SANITARY NO. CONTROL NO.
O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
WE- BLDG ELECT PLUMB MECH
N<
LICENSED CONTRACTOR'S DECLARATION
5 I humn firm mat I am ncc.scd meet f Chapter 9 cson meneio Job Description
y u ptovlsiofe aa RELOCATpp pp U--Ir'ppprrSs��dppp��mm
i-sewith Section]WO)Of Division3oflhe Business ane Profcninnn Q+de.and my licenu +..y.a WXLDj w
in full force and Rea r 0 ■b
a p a+ Licer"CIa. Lic.p
:o a nae eom actor f �S:Lr
?LL u.an A C ECI"S DECLARATION
;—
I nnden dm,• all lir records DEC 0 3 2001
1 to C O Licc Pr c nal
41
OWN[RA UILDER DECLARATION
an v 1 hereby affirm thm I an exempt front the Contractor's License Law far the BUILDING
I- a following=son.(Section 7031.5.Business and Professions Code:Any city or county' $25000
_ a
E D mlil n romtmn otter improve.demolish or rt vrvcmm
which requires a pc fr Pair any
pdononsiesuancaulmnit(.the thezploo ,fine mchpermlr Licensfile.e a- herplrem
mrtanni liccnwitpursuhni.700dpmvisi,imfinetheStr i,LicenseLawls.,Cor9 t's I^d .a rp� �; 1 . Valuation
or that he is cxea Scction4000)of e basis
or t the alleged
xuand Professions Coda (•. 4J•a E t�3'D17 V �1,;jll�'I'4 .:I ^d}sr^
or that he is.3155 b anefmm-and the basis for the cts the cacmpnt to Any violation
of Section a Iran by any applicant fears Permit subjects the applicant to a civil pcnmry
or oat are Iran hse Wnatm dollars rasa». 106pN Nl°C7bNDATI ON ' '^ Occupancy Type
°1.asy,
er oflhe pmFenormyemecploywith wagesas Meir sole compensation. 102 - PIERS
will do thhe'work:'and the secretion,is not Intended or offered for rale(see.]aw.' 10 3 - UFER Required Inspections'
'Buxinesi and Profm
essions Code:The Commer'x License law does not apply to an 9 P
owner or property Who build,or improves thereon.and who does such work himself 104 - REBAR
or borough his o n however. provided that such improvements me not intended or
ilding or impmscmcm is sold within one year of - --.. ___._. _. ... _. ... ___.
om-ve for he owned,.Ir.y will have IM1<M1UN<n of proving that he did not Wild or
105 - ANCHOR BOLTS
improv= farposeo 106 - SEWER & WATER
_.. ...__ —'202 - UNDERFLOOR" PLUMBING_-. :.I
-01.as owner of the property_ exclusively xclusively contracting with licensed'contractors to
construct the project(Sm.70a4,Business and Profession.Code:)The Contractor: 203 - UNDERFLOOR MECHANICAL" -
License Law does not apply to an owner of property who Wiles or improves themon,
and who.contracts for such projects with a contmctoas).ficensed.pursuant la the 204 — UNDERFLOOR FRAME---- ----—
Cont'sem's License Law.
°I am pat.I W c,sec. .B&P C for this reason 205 - UNDERFLOOR INSULATION
Owoar Date 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I thereby affirm under penalty of perjury one of the following eeclaraliom: 303 - ROUGH MECHANICAL
° I have and will nomotmn .Cenificale of Consent to self-imine far workers 3 04 - ROUGH ELECTRICAL
Compensation, as provided for by Section 3700 of the Labor Gide. for the
performance ofib,work for which this permit is issued. 305 - FRAME
❑I have Bad will maiamin worker's Comfrnealrni insurance,as required by section 3 06 - HOLDOWNS
37W of the I.uWr code,for the Performance of he work for winch his pmern is 3 07 - INSULATION
issued My Work-en's Compensation 1 ranee canter and Policy number um
308 .- SHEETROCK,
earth . p I Policy No.:o3/aa�—d7 D . , ')•;: f:l �
' ,+ I CEf IDCA ON OF E%EMPTIONFROMWORKERS'a "- a•.` t� j -i,3O91'-f EXTERIORtsiLATH•
COMPGNSATION,INSURANCG" . . ......._. . . .. ._._._.___._...__..
--310-',_._.INTERIOR--LATH . _.......___.._...._._. ___..
(This section need at be completed if the perm it is for one hundred dollen 3111 ' SCRATCH COAT ' • thrum+.�:::' f.:l .'
(SI00)mless.) _ t
t i cenif thatin the perfomtancc of the work far which this permit in issued.1
313- ROOF• NAI3 _ ... __. _ ...,_..._.._.. _. .._.L,_.._. .. ..
shall not mrs,oy any Person in any mmncr sa as j6 become subject to the warloos 501 - FINAL ELE CTR I CAL'' ENERGY`
Compm
cndon laws of cauhmu.0a1` 502 FINAL. PLUMBING ENERGY_..
Applicant _. _ _
NOTICE TO APPLICANT: 503 - FINAL MECHANICAL' E14ERGY
become subject tb the Worker's Compensation Provisions of the Labor Code,you must
O z0 fortsithcomply with rush provisions orhis farm,roanxcreated!orwked. _ _ _ 5.04 - _FINAL . BUILDING ENERGY - -,,, _
CONSTRUCTION LENDING AGENCY" 505 - FINAL ELECTRICAL •"' - \
a >
"I hereby affirm that there Is a constmction lending agency for 1h2 kisormace 5 0 6 - GAS TEST _
of tAe work for which his permit is issued(Sec.309],Civ,C.)
.. "'a Name._ ._ _.. _. _. ,. -: ._g. - _
p z nder'sAddress 507 -- -FINAL PLUMBING,..
U O b eerily that I have read this application and state hat he above information is 508 - FINAL MECHANICAL
correct.1 agree to comply with all city and county ordinances and state laws orbiting 509 - FINAL GRADE
O.V to Wilding contraction.and hereby mthad.erepresentatives othis city toenter upon 510 - FINAL PLANNING
y �] the aM(We)agree to property for inspe d km,brunde.,, . , - - p
IWpil,nemsme;ma,`dni addkcfa hmayinheCity ay Cupertino stsuid 514 FINAL PUB IC WORKS (//
V1 liabilities,judgments,msn and penis which may in any way accrue against said
U Cit-'n consequence ofm ng of Nis pe lit., �-• /1s
30UR`LAW( ATIO A, ANDw'IL 'OMPLY WITH ALL NON-POINT' Issued by: Date V/
Signa of AppiicmUContrmba - Date" ._` Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the a i,idant or forum building om pam stale or handle hvallom.,ad.] Type of Roof_ .:-- - :=-- -- -- - - --
as defined by the C.,enion Mootipul Code,Chapter 9,12,and the Health and Safety yp, a ., +,a.T iL a, M1 - � 1 1
Codes lion 25532(.) . .i� a t:r'+ , r l / .l \ �.r .t S L
°Ya'' N All roofs shall be inspected prior to any roofing material being.installed.,—
Will
nstalled.,_W ll the appy, m r t W Ia g p �, q Pm t e' whim If a roof is installed without first obtaining an inspection, I agree'to'remove
c it h mdr dire ta dgf d by t Bay A A Qua]by Management
Dismet - all new materials for inspection._Applicant understands and will comply with
A °r - all non-point source regulations, • .,
`l aaa��F��� ,1
1 have read the�hazar mtadal. rcyu rcments under Chapter 6.95 of the
Califomie HEalm&Safety Curl,Sa bra 25505:25533 Bad 25534.bmdcrstmdtWo _
if me W ilding docs not currently W a anam:that it is ary Rsponsihili y m notify the
MC 1 a Iht RGYIttmC mY31 I%roll prtar Io inYeneC of a f.'NhCele of
°r Signature of Applicant Date
ow _ aunim:mf.gem Date All roof coverings to be Class "B"or better
OFFICE .. .. - .. _