04120111CITY OF CUPERTINO
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'BUILDING DIVISION ' PERMIT -
CSL!TRACRR7N.ORMATION
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SU17DINGADDRESS:
SOUTH BAYCONSTRUCTION CO
"'04120111
10251 TORRE AVt If 1:38
OWNER'S NAME: '-.
FBRMTT ISSUE DA'Z'E -
CUPERTINO TOWN CENTER LLC
511 DIVISIOU
g;
SANITARY NO. CONTROL NO.
408)379-0400
ARCHITECTIENGINEER: ... -
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- BUILDING PERMIT INFO
BLDG ELECT PLUMB, MECH
- LICENSED COMMACTOR-SD IARATION
JpbDesln Description '
p
1 by afRrm met I ane licensed under orgy of Clupur 9 (commencing
wlm Sec 7 )Cif Dl ialoa3of thalloid s Prof Code. n myliceauis
in rail Tome 'affect. 7,
REVISION--IN HOUSE ONLY.
uewm cl Lb,« '
Dam Canlr
USE '
NO..NEW' PERMIT ISSUED/' .ORIG., #04070059: - --�-
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EC
RC DEC TIO -
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' OWNER-BUILDERDECLAMTION
I hereby affirm mat I ata exempt from the Commutes uccom law for the
following reawn. (Switch 78313, Buainen tad Profession, Code: Any City Or county
which requires epermit m construct, elect, improve, demolish, or repair any aWdum
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prior In ill issuance, elan requires the applicant for such permit to file a signed auumenl
that beialiceucdPurnmstofind providamnfthe Commune. U.nsoLaw (Chap=9
Sq. Ft. Floor Area
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Valuation $0
'(commencing with SeNon 70D8)of Division 3 of the Busincvmd Profusions Code) or
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cut he is exempt thcmfmm and the bubfor, do alleged Cameroon, My violWon of
APN Number
- Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant m a civ8 penallyof
Out mom man me hundred dollars (S5031.
36940017.00
❑ 1, u ownerof the property, or my employees with wage u their sole compensation,
� '. t '.- ',-,,., Ins ections
will do thework and the suumme is wimambelmo(feted rornle(Sec. 7044, Burnams
and Prbleuiana Cade: The Cm ommes Lbws law don cel apply m an owners of
The
. ., .Re uired
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property who builds tar thereon, andwhodouauchworkhlmnlfm through his-
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Ownemploywa, provided thin Inch Improvements am notimendM Oro@red fersab. If.
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meawe OF
l the thuimprovermm�bahld wliinot ear or improve
Wilde, wiB love the buNan of proving that k did ws Nlld u improve for purpose m
Wilde, will
cobs).
❑ 1, Is Owner of the property, am exclusively contracting with licensed conaacmn in
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construct the project end Profession Code:) The Cmbacur'a
and,
cease law clow not apply c m owner of property who builds or impraw O thereon. and
apply In in wnerBestof
who contracts for such projecu with aconuanlorts)Iicerued Dunwantuthe Conuectoru.
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n Law. . n. �.BdPCfar
\
0 1 a m exempt uncle Sec cob Tenon
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Owner Data
WORKER'SCOMPENSATIONDECURATION.,—,,, -, ,,
I hemby affirm under penalty of perjury one of the following dcdaradow.
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I ham and will maintain a Cortificam of Consent u self-inum fm WorimelCompen-'
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wion, u provided for by Section 3700 of the labor Code, ran the performance of the
wank for whim this permit is issued. .-. -
❑ i here and will maintain Worker's CompcuaUon Irwranae: as required by Simons
3700 ofthe UWrCode.foreupMmmmceafthewarkrwwhichthispemritis Was .
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My W.a Crao a IuuruNe canner Policy nu Marne.
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CER (FICA OFMEMPTI ORKERS'
,
COMPENSATION SURANCE
ITh, suction wed notbeeampbud if the permit is fora mmouluddallan (Slee)
or leu.)
1 certify that in the perrormewe of the week far which this Permit is Issued, I sledI no,
employ any person in my mannerm as to become subject to the Werkan'Compensation-
Laws of California. Dau
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Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Woftes Compenutlm provisions of the labor Code. you must
foMwith comply with such provision or this permit Mall be dscmed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them Is a consu nednn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. Cd
Under', Name
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Lender's Add.
{ - 1 certify that I form mad this application and sum that the above information is
mach 1 agree to comply with all city and county and mu law relating
ntdinmms
aumonmmpresmuuks of this city menurupon the
and a
above-mentioned finemnify an PuRoua
.1buyungeotioned property for
(We) agree to cost, indemnity and hwp harmless the City ofe ,ai ha idItImit
to am
City
j Iiabilice,judgmenu.cosu andexpenua which may in any way eccroc ,aim nisi City
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,
I. cirrignimencs, of the grunting of this permit.
' 'APP UNDERSTANDS AND WILL COMPLY WITH ALL ON. IM
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Issued by: Date
S U ONS.
�d
Re-roofs
Type of Roof
al ApplieanUC au
iUS MATERIALS DISCLOSURE
HAZARDOUS
Will the applicant or future building or fundis eamu omaterial
Chanumre
H
dcfiwd by the Cupertino Municipal Cade,e. Chapter 9.17. and ft Health and Safety
add. Switch 355320)7
All roofs shall be inspected to any roofing material being installed.
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❑Yea T'
prior
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future building =open, use squli m sal or devices which
it hacomou air emuminan s as defined by cu Bay Are, Air Quality Management
all new materials for inspection.
Diuricl7 r
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Ely. t}nu
I haw mad the hammousmaunala mqulmmenu under Chapter6.95 ofthe Color.
nuFbelth&Barely Cade,Sec' ag550A HAmmonsi334.1 undcrnan the building
of corm tly haro L Net it is my mpaulhilily u notify the cuP of me
the
reyu kh elpnorminumwofscrnilkauora pancy
Signature of Applicant - Date
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All roof coverings to be Class "B" or better
n arInmodxdagent ate