08030056X.
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
10400 N TANTAU AVE
OWNER'S NAME:
APPLE
PHONE:
ARCHITECT/ENGINEER:
1 hereby affirm this I am licensed under previsions of Chapter 9
with Section 70W) of D' ' 3 of the Business atyl.prukuh ns Code, an
In full force and drecL L7
License C1 Lie. i
Date 14 Contractor
ARCHrrEECIS DECLARA N
I understand my plans shall be used as public records
SOUTH BAY CONSTRUCTION CO
170 KNOWLES DR
(408)379-5500
PERMIT NO.
08030056
PERMIT ISSUE DATE
04/02/2008
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
rsrnm. -Ing Job Description
mrlKeaseia COMM d L TI ; ROOF SCRN, NEW STRFRNT, COURTYRD
MODIFCTNS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from We Contractors License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to construct.aher. improve. demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed su errtent
that he is licensed pursuant to the provisions of We Contractor's License law (chapter 9
(canmencing with Section 7000) of Division 3 of the Business and Professsiiona Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applltam for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SS00).
❑ L as owner of the property. or my employers with wages as their sole compensation,
will do the work and the sttuctue is not intended or offered forsake (Sec. 7044. Business
and Professions Code: The Contractors Lacers Law does not apply to an owner or
proper who builds orimprotes dumicit, and who d oes such wort himself or through his
own employers, provided that such imprus Bents are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
EL I. as owner of the property. am exclusively contracting with licensed contractors to
nstmct the project (Sec. 7044. Business and Professions Code:) The Conductors Li-
cense Law don not apply to an owner of property who builds or improves themon, and .
who contracts for such projects with a comractor(s) licensed pursuant to the Conttactora
License Law
❑ 1 am exempt under Sec B k P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby afrlrm under penalty of perjury one of the following declarations:
❑ I ham and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this perm)t is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurances carrier and Policy number are:
Carrier. W tt oo—S L 7 n�+" Patey No.
'CIERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($ I00)
or loss)
I certify that in the performance of the work for which this permit is issued,) shall not
employ any person In any manner so as to become subject to the Workers' Compensation
Lawn of California. Date
Applicant
NOTICE TO APPLICANT: Ir, after mating this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shallbe deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction n lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
1 certify that I have read this application and state that the above information is
cored 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
alcove -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilitles,judgmema, costs and expenses which may in any way accrue against said City
inpoce of the gmmting of Win permit.AUNDERSTAND A WIMPLY WITH
a ntfConuactor Dose
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)7
❑Yes No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes No
1 have red the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health k Safety Cork:, Sections 25505.25533 and 25534.1 wWcrosand thatif We building
dos n c �W� tntly
. Ft. Floor Area $50000 Valuation
31609029`
Required Inspections
Type
Issued by: Date 2-
Re-roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date