04080066CITY OF CUPERTINO .
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,ONTRACTO3CR, N�"
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BUILDING DIVISION, PE
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BUILDING ADDRESS:
SOUTH BAY CONSTRUCTION CO
PERMIT NO.
ENC 04080066
OWNER'S NAME:
PERMIT ISSUE DATE
E:
SANITARY N OL NO.
ARCHTIECT/ENGINEER: -
BUILDING PERMIT INPO
BLDGELECT PLUMB MECH
I1 o o I�
LICENSED CONTRACTOR'S DECLARATION
-" - _ Job Description'
al 1 am Iim under provisions of Chapter 9 (mmcn=ing
I hereby affirm Nund m
7de).17D A.JofdnB eoiuns Co e. arW liceve is
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mMS.
Lima Clry{a Lm
REVISION-RELOC. TRASH ENCLOSURE &
Date%cantunr
ADD DENTAL EQ. ROOM IN GARAGE
ARCHITECTS DECLARATION
1 unticrsunJ my plans shell h tend a public rtcnrtls -- — .
NO NEW-'PERMIT ISSUED/ ORIG. #03080-088-�
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LiccnsedProfessional
OWNER-BUILDER DECLARATION
1 herchy M. her I oro exempt fon Ne Cantrsctal's Licca¢ Law for the
following neon. (Seclian 7031.5, Bulinus and Profession$ Code: Any city or county
which requires a permit to construct. alter. Improve, demolish, or repair any structure
pd., it, its iuuanm, eon requites Me applicant far such permit to file a signed staurnmi
does he isllama] pusuanl to the provisions of Ne Conaumr's Wave Law(Camun, 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7(IBB) of Division 3 of Me Business and Profession Code) or
Mal he is cumin therefrom and Ne built for Ne alleged exemption. My violation of
APN Number'
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Occu ane Y, e
p y '7 p
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil Penalty of
non mom Man five hundred drums (5500).
❑ I, asowean of dre pmpmy. as my employee with wages as Meir sale compensatlon,
• 0 -Required Inspections - • " -
will do the work and Me structure is not intended mefrend penal. (Sec. 71114, Business
and Pmfeamins Code: The Ceouacnrs Liceve Law dons net apply n an owner at
property who builds marrows thercon,and who dasauch work himself orthrough his
own employcn, provided that such improvements arc nnimended or offered forsale. If.
however. the building or improvement is sold within one year of compledon. the owner-
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builder will have the burden of proving that he did not build or Improve for purpose of
sale.).
0 I. as owner of the property, am exclusively camauling with licensed contractors to
convect the project (Sec. 7044. Business and Pro(msions Code:) The Contractors Li-
cove law door not apply in an owner of property who builds or improve thereon, and
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who contracts for such projects with aeonmctm(3) Remand pursuant in he Contemmi's
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Limas" Law.
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❑Iamexempt under sm. , B S, P C for this reason
Owner Dale
WORKERS COMPENSATION DECLARATION
1 hereby alBnn under penalty of perjury one of the following declaration:
I have and will maintain a Certificate UfCmscal toself-insum for Warkefe Conran._
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smien, as provided for by Section 37W of Me labor Code, far the perfmorm. of the
Wfor which this permit is issued.
1 have and will mainuin Workers Compensation Insurance, as required by Scotian
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37W of Mc labor Code, for Ne performance of lie work for which this morn is boom.
MY,
y Workers Compere I Immar�la �ca�scr �d Polity n�uv�,
el; IV 1NIK/✓,I1pNe.:(�U
CERTIFICATEOO EiEMPnONFROMWORKERS'
COMPENSATION INSURANCE
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(Mis section need oat he complend if the permit Is foronc hundred dollars (SIM)
or ins)
I certify the, in to performance of the work for which this permit is issued, 10,11 not
employ any penton in any manner an u to became subject to the WorkersCompensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. after making MIs Certificate of Exemption. you should
become aubj¢t to the Worker's Compcnsi previsions of the lahnr Code, you mute
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm dot Nen is a comuuctina lending agcmy, for the performance of
Ne work far which this permit is iaaed (Sec. 309'i, ON. C.)
IandcrsName
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Lender's Addrors
I cenify than 1 have road this application and stun thio Ne above information is
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correct. l agree to comply with all city and county adhances and sum laws mining to
building construction, and hereby authorise mprcsenutives of this city 10 enter upon the
move-mentioned popery for inspection purposes.
(we) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and.expenses which may in any way acme against City
we11
NERSTgan"OMPLY
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�f/R
"weTeUNof
APPn CANan
WITH ALN000fffiii POINT
Issued b Date
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Re-roofs
Type of Roof
I
Sign ApplicuVCoDate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantar fumes buildingoccupant stoworandth
az defined Health anmaterial
the na Municipal Code. Chapter 9.11. and the Health and safety
t.
Smut.. 2553](4)? J
32(x)7
❑Yor I�Nu - -
All roofs shall be inspected prior to any roofing material being installed. -
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=' If a roof is installed without, first obtaining an inspection, I agree to remove
Will the applicant or f/amt building Occupant area egmpment er devices which
It hmamaus air commminamu as Unlined by the Bay Area At, Quality Management
all new materials for inspection.
Dis,let?
❑Yes IN.
Ihave real the huatMns materials requirements underchapn, 6.93 of the Califon
ria IN& Sa(cly Code.Sadom 75505,255]7 and 255Ja.lundcrauM NuifNe Wilding
JCm t eaaeally have a on 1 is my rcaposulhlllty n m ary NC ox,upNI of NC
reynn m hi moa, eta iasaandeof.ccnillme;f ry.
Signature of Applicant Date
All roof coverings to be Class "B" or better
own
ra hodxetlasen Dm.