01040046OFFICE
CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
13UILDING ADDRESS:
PERMIT NO,
6 RESULTS WAY
SOUTHBAY CONSTRUL"ION
01040046
OWNER'S NAMH:
AI'I'I.ICAI']ON SUB DAJ H
ACAN
511. DIVISION STREET
04/11/2001
PHONE:
SANn'ARY NO. CONTROLNO.
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Mal
ARCHIL ECT/IiNGINEER:
BUILDING PERMIT INPO
BLDG E-EC]PLUMB MECH
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LICISNSED CONTRACT OR'S DECLARAI'[ON
Job Description
O% - O
I n.rchy affirm that 1 em licenwd umler pmvisiorn of Chapmr 9 (commencing
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with Scctinn]1MNp of Divi.ionJnf the Business nnJ Prnfcssinn. C.de, and my licence
ce
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I. In full fnrCC un. lc
en cls =Q� l.i.N�
EXTERIOR SIGN.
O d
y
Dam- Cnatmmor
ANC111'I'EC'I"S UIiCLARATlO
F' g
1 nndcnlmul my door, hit M nseJ ns,,llblic reeoNx
FINALE
ca ce p O
D
Limmed Professional
OWNER -BUILDER DECLARA'T'ION
LL n In
I hereby aflimt that I am exempt from the Contractor's License Law for the
Calc
C: Any
.JUN 2 0 20 01
city m county
following ...on. (Section ]0315. Burome,. cold Prod-city:
$�$
61 �
stracium
Pjtrh y 1 n 4 ti l IIIIl. II IJV n I I pemolish, for b l sed eat
Sq. Ft. Floor Area
�v an on
a. a
that h 1 II It top I h c I I r I L. (Chapter 9
be , u tl S 7003) ffe .- fm . .. B dl f : Cadet
BI,IIIt.�IIV
nr that he empt Iherdmm cad the bu r for the alleged eae npl on. Any Jnlut ire
of Section ]U) I.5 by any applicant for It permit xubjef the applicant to a civil penalty
APN Number
Occupancy Type
of nm mo,e than roe hunarcd delta. D50(n.
❑ I. as owner none pro,eny, or my untployec. with wages as their cake vempe,nation.
37520042
will Jo Inc work, and the sesame i. un Intended or offered far sale (ties 7044,
Ilun ml I'rofun s Code: I he Omooloon I Liecnw I,aw tine_. ant apply to II
ball
Required Inspections
`coli Who builds or impowev ntenon, and whit docs ouch work himself
or through his own employees. provided lien such impmveanents are not intended or
101. — FOUNDATION -
III for sale. IL however. the building or improvement is sold within one year of
the oer-builder will proving have the burden of pving mat he am not Wild or
w,t
1.03 — LIFER
iompletion.
improve for patposeof.mc).
104 — REBAR
0 I, a bone of me property. an esvluJvdy cornouring with liccmed commcmm m
u.I the`pboieel (Sce. ](..a, Bo, and Pmm. . Come:) The Con ara.Ior.
n,�.o molt
105 — ANCHOR BOLTS ,
mr .nen protect, avian a ommmolr.) heen.ed par am m Ise
re en e Lnw dnc. not ttpmc In;In awncrnf pmlla.y wnn nnhdw oI' Impb ran 1,, 111,
mod who
304 — ROUGH ELECTRICAL
Livens
p, License Law. ,
❑lam encnlpl under Sec. ,BA PC for this rca.nn
01 mom crop,
505 — FINAL ELECTRICAL
Date
514 — FINAL PUBLIC WORKS -
Owner
WORKER'S COMPENSAHON DF.CLAR61'ION
I herehy alBno under penalty of Joe Jury ane of the following declaration.:
I have and will maintain a Certificate nl Connenl m w1biowre lot Workers
mtpen t m, no provided for by Seen 3700 of the Liman Code. 1'nf the
cefoarans ce .1 he work for which this reboil is i ... ed.
01 have and will nminmin Worker's ComPematinn Insurance, as required by Section
37(0 of the Labor Cute, for the performance of the work fur which this permit is
sued. My Worker'. Contperionion Insurance currier and Policy number are:
carrier:_ t 44 Pnn No.. 1.3D 402 —01
y
CHRDIBCA'HONOFCNEVI ION FROM WORKERS'
COMIIF.N9A'I ION INSURANCH
('Otis section need not be completed if the permit is for one hundred dollars
!EI W) or les..)
-
I really that in the perfnnn:race or the work for which Ihis peril i. is%und, I
.hull not employ nay person io any nnnfnc s- a. w nemnte o bjeel to the Workers'
Cnmpcn.ation Luws of California. Dale
APphcant
NOTICE 'ID APPLICANT: If. alter making this C,mixetn of Esentpion, you should
httime mbjecno the Workers, Compensation provision, of the Lobtn Cale. you amu
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limhwith comply with such Rmvi.iom car his pe mtit shall he Jecand revoked.
F+
CONSTR, NG Y
o n can runin.LITNTI
Icnding agency lin the p:rfnrmuna
I hmchy vain, that leading aRe
is n nn.Of
W
fener (See
o1'Ihc work for which Thi\ pmmit is In.nvJ Ise. 3(19], Civ, L'.)
QLmdcr's
Nuuw
-
7 Z
Lender's AJA¢n.
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1 comfy that 1 have mad this application and one that the above information i.
I.. P
correct. I agree to comply with all city and county mahmancee and state laws miming
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rebuilding con.wetion. and hereby amhorim repreunmtives of this city to enter upon
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the above -lass inned pmpny for itnpection purlx,as.
F A.
We) ag ocia eve. ndernni l y and keep harrtdc.s the Cityot' Cnpcmoo againal
W
Ilabilille., judgment., coos :Intl exPI whirl, Indy In any way theme cepa n ' said
city lv conscquencu or hegmmia,ol his ,I I.
APPLICANT UNDERSTANDS AND W11.1, COMPLY WITH ALL NON POIND
/�
Issued b L / 7�i� R-'��C�., Date' �/ �+' /'V/
SOURCEk ' ..\TION i/ JI_O'
T -I
Re -roofs
Sig ams of Appl .101'nnlmcmr Dme
HA"RDOUS MAH IIALS DISCLOSURIi
Will the applicant ar more building Occupant.torc or handle levooku material
Type of Roof
rax AennW by the Cnpnioo &I copal lc. Chapter 9.11. and the Ilea th and Safety
.
Colo, Section 155.3'00!
0Yas "n
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfalarebuilding Occupant e.eequipment ordevices whhit
If a root' is installed without first obtaining an inspection, 1 agree to remove
soil haztNon, an contaminant, -trial neJ by the Bay Arco Air Quality Momagentent
Distdm
all new materials for inspection. Applicant understands and will comply with
❑Ye. lGuo
all.non-point source regulations.
I have read the hvardmrs nuncred, rcquircmvnts under Channel 6,95 of the
lullonna I Ien11h h Safety Cnof Seellonv 255115, 25533 ano125510. undcrxuual ILItl
if the ndilding Anes sol vubenlly have a tentmt. Thal d in my rmpon.inility re notify the
eastnl of me goi m.nt. which Inca be mel prior m novena of a Cmireme of
Nm
`apaney
Signature of Applicant Date
All roof coverings to be Class "B" or better
o».neror�n ni7odagent Dale
OFFICE