00080110CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDINGDIVISIONPERMIT
13UILDING AIIDB030 TORRE AV
SOUTHBAY CONSTRUCTIO
'RMITNt).000801.1.0
OWNERSNMpl_E COMPUTER
511 DIVISION SI-REETApPI.ICArRggal/TfS/='0OL71
xPHONE:
(408) 379-0400
SANITARY NO COKIHOI. NO.
ARCHITIiCHHNGINEER: -
RuII,DING I'EItMI'IINFO -
BLIH'i I.1 Cf PLUMB MGCH
fJ IJ 1=J 1_I
LICENSED CONTRACI OR'S DECLARATION
Job Description
1 hemny of 'bar 1 vat licensed under pmvuiom of CCaper 9 mommendng
Ill tile 11
wihSectionann(nnfDo, ...mf im,andL,inn,Coce.andntYheca,e
COMMERCIAL DEMO - INTERIOR ONLY
rill fin a nd wfecl.
-
I.In
ianse cla" Lie. a
DareContractor
AN011 rECI'S DF,CLARA'r1ON
I understand my plan, shall he used as public recori
I-wer,c] Prohssiona[
OWNER -BUILDER DECLARATION
'
I herehy affirm Iho I air c,eanpl fent the Cumrumor'e Licenw I.nw ter the
fallowing n'axt. (See n 7031 5, Ifo,IttCxs and Poll . a Code Any oily or cl only
il ILo
which rcgmim it pc alter. Imprmc or repair any
also re uimtrue,
h permit I
for tach pe,ntinn lice a
statement prior m ill issuance, also
the the
Sq. FL Floor Area
�iDeQl�{10
morsenl
he oncingnlpurxtion7lnepnwiinn,eflhe Law (Chapter
n at meme,andMLe."mr,
ode)
ofthe Professions Gale)
(commencing Division 3 of the
(comm
I%e with Section
om ane,
lateral
alleged ra
of that he i, exempt therefrom and the basis for the alleged
he
III Any violation
of semen mu 5 by uaty appfipam nate a per,tdt ,taniepl, the anplipam m a eied penally
piph,c
AP);
Occupancy Type
of amt amore In lice hnnama deharr r85001.
01. 0t7t
❑ 1. u, owner of Inc pmpeny, nr any etnpinyccx with wages as their sale coniper,ation,
I6N&q`nIWRN2B'91pB0NS
rill do the work, and the amicare in not intended or offered for sale (Sec. 7004,
Baames, Prefc, am, Code 'Me Commemr, License Law' doe, aa, apply m an
aad
awner of prnpcny Who huilds or improves thereon, and u does such work himself
NO ASS
or through his treat employee,. provided that such improvements am not intended or
d
offered l .d If. h -h IM1 loathing p I nt i, Id 9th Ymnr
,npl h II will I- (lie i 1 II lig that he JJ IhuilJ or
np/
Z
f I I f i t
,,
�J\
tier f d pmpc, n ly contracting with licensed contractors m
7
con cleat (cep. 7(wa Bnx oro and er n.. n. il,d 1 The c fit s
consumer
n theLaw
Law doe, nm appy a n owner of property who ,olide se improv,
do
ajms
t to the
mol who for w with a rommemr(s) licensed pursuant m the
aw.
ca w.
r, ca
Cnnu:amr'y
11 an pt 13R1'C lint this r_c
'
'OwnDnlc JoD
-
N'ONKE COMPFNSA'IIh9ITEC ,RATION
11 airy difnm ua r penalty of pcpary one oflhe folluwm,declarations:
❑ 1 have and will maintain u Certificate of Ceanat it, ,elf insure -for Worker's
\
Conipemation, as provided tar by Suction 3700 of the Luher Code, for the
perlbrmuncu of it,, wntk for which Ihi, permil Is i Ned _
❑ 1 have and will mnialain Work,,', Coavpcnsmim finer nap, as reyalred by Section
7700 of the Labs Cade, file the perfimnance of the work for which this permil is
\\1
,wed. My Workers Compensation Inwmnce carrier and Policy number am:
CamcrPolity Na,
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMI'ENSArION INSURANCE
(this wation need not he completed if the permit i, rnr nme hundred dollar,
S103) or less)
-
I certify that in the perfi,nal of the work for which Ihi, permit is issued. 1
shall not employ any person in any manner so a, to become subject to the Workers
Compcnsminn Lows of California. one
Applicant
'
NOTICE'I D APPIACAN'I': Il: ahcnneking dtix Ccniti,aac F Exeanpllnn. you ,hnold
become xaoec, au the W akeaM C ... nwavation pmvi,ioau athe Labor Code you most
fonhwi,h comply with such provisions or this permit s,all he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby alarm that there is a construction lending agency for the performance
it the wad, far which this pcialf is issued (Sec. 3097, Civ. C.)
iLender', Nun¢
Lender', Adds„
,
• -
faa,ion is
I certify that I hove m.d this .application and slam (Ithe a,ovc inm
oma. I agate to comply with all city and roomy onlinanpcs ad state laws (.filing
m building construction, and hereby uniform mpaw,tankc%of this city to enter upon
s the al tolnlioned property for impaction purposes.
(We) agree ill save, aid in iy and keep hnrmlcsa the City of Cupcnino against
1 Ilahilities, Pd •.. tans, cost, an patsm, which Only in any way accmm agninsl .aid
�
Jl"/
u,perl.
Cy iina u Or Ii N df thismi
' APPL U A N1) ILLCOMPLYWI'rH(LLNO t -POINT
/
1
jtitiUCd by: Date
Re -roofs
in so n pImm I cm Dam
HAZ\ S hMTr:R1ALS DISCI. .URE
In do appcicom marc huilding cecupant'nal hardle hmardou, material
Type Of Roof
a, th, ed by the Capemi a Mantaipal Code. Chapter 1). 12. and the Health and Safely
Cods, Scotian 25532(a)P
❑Yes ED Ni
_
All roots shall be inspected prior to any Tooling material being installed.
Will meippf.ali, faarc haildiag occupant use Odcipmem or de.mc. which
If a roof is installed without first obtaining an inspection. I agree to remove
emit hamrdous air can uninenlr as defined Fly the Bay Arca Air Quality Management
all new materials for inspection. Applicant understands and will comply with
Di„ric,?
❑Ycs 0 N
all non -point source regulations.
I have ,:at rho rnµairemm�lx under Chapter 6.95 ill the
Culifinniu l Icahn &Sucellon, 255115.''_5513 nn: 125534. I wdc,tead lire,
if the build nn 1on lCwnL lhw it anayrc (wndbility enol ty the
Vnnmri;Js
Pam, - eq itmua he mel prior m is of 'enilicum of
!ante
°a !
71W.
Signature of Applicant Date
All roof coverings to be Class "B” or better
o rte a ant agent Dam
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