05020030CITY OF CUPERTINOz#
BUILDING DIVISION PERMITfCONTREiCTQRiNFURMATIUN
BUILDING ADDRESS:
SOUTH BAY CONSTRUCTION CO
RL4R N005020030
OWNER'$ NAME:
PERMIT ISSUE DATE
E:
SANITARY NO. CONTROL NO.
(408)379-0400
ARCHITECrrENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
1 hereby that 1 am under ProvisionsofCluper 9 (commencing
Job Description
pan
wide ) of ftho Bal
DiW,lon3of the Budneuand Prafcuiov Code,md myIiceuoe
f
li mi 11of
m flif 7
Lleve Claes L'c.gIsr
TI--CHG CLOSET TO RESTRM
Dam Contracto�ryw
ARCHITECTS DECLARATION
10 f
1 understand my plan shall he uaed as public rearm
Licensed Poureadonal
OWNER -BUILDER DECLARATION
1 hereby ,Rine that I am exempt from the Communes License Law for the
following mason. (Section 7031.5, Business and Professors Code: Any city at county
which mgutre, a Permit to covin, alcor, impew, demolish, or repair any immure
print 0 its issuance, also requires the applicant for Inch permit to Ole a Blend comment
that he is licensed pursuant to the provisions of the Container's Lien= Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 7000) of Division 3 of the Business and profession Code) w
that he is exempt therefrom and the bash for the alleged exemption. My Woiadon of
Section 7031.5 by ally applicant for. permiuubjecu site applicant to a civil penalty of
3 6AFNI'falitribelO 0
Occu anC
p yTy�
net mos Nan five hundred dollars ($51)(1).
01,uawareofthepmpeny,mmyemployerswith"a uthroesoleemmpenutlon,
will do the workmd Ne awnure is notlntended oraeered fonde(Sec. 7044, Business
and Profession Cody: TM Comtranars L aceme law does at apply to a owner or
fl f3 Required Inspections
property who builds orimprowa thereemandmaomhwork himrelfethrough his
Q
own emPloyeu,provided that such imPmwmems,are not loundledmeedforal.IL
however, the Wilding or impewnenmid yearefcle the owner.
BO'"M`n
asp
Uy/A``T`Vlryldp/��l.lYl1
fn.
bulWm MII have the bumm of proving that hea did ban Mid o Improve or purpose of
tae).
A
❑ I. as owner of me property am exclusively contracting with licensed comeuaon in
connect then not (Sec. o In Business and Property who v Code:) The Cnhereon. std
cease Law dos no apply ts owner property ice Milds or impmw and
who contracts for such projects with awntratm(O licensed purattant to the ConuaTors
e er Conner,
License IoW.
❑ Iamemmptmneer Sec. ,Bk PCfermismmm
coma TIO
p
Ully
WORKER'S COMPENSATION DECLARATION
�f
1 hereby aRren under perslty of perjury was of dm following declaalou:
have and will maintain • CeNOnm of Cement e alf-ivum for Worker's Cooper.
saden, as provided for by Section 3700 of the Labor Code. for the performance of the
work for which this permit is issued.
❑ I haw and will maintain Workers Compensation Insurance, is required by Section
37M of the Labor Cede, for the performance of the wmk for which Nu permit is Wasti,
My Wenpce. Compensation Instances carrier and Polity number �n
Cartier: nL Pnd3 LIC Polity No.: s 3 nZLo-
OIgj
1 V4D&-._ . EQTJf9CA7E OF EXEMPTION FROM WORKERS'
��VCa /mac COMPENSATION INSURANCE
(The section need not he completed if the Permit is for one hundred dollars (SIM)
or leu)
I unify that In the performance of the work for which this Permit Is issued, I Mall not
employ any person In any Mercurio u in become object to the Workers' Compwation
Laws of Cdifomle. Date
Applicant
NOTICE TO APPLICANT: If. after making this Ceeincam of Exemption. you should
become SAW m the Workers Compenndon provisions of the Uw, Cade. you mum
foMwim comply with such provision or this permit shall W domed revoked.
CONSTRUCTION LENDING AGENCY
1 hemby.trim that tem is • cormustioa lading agency for the perfommecof
the work for which the permit is issued (Sec 3097, Civ. C.)
Landers Name
Lenders Add.
I certify that 1 have mad Ws application and sum that site above Information e
anaL I agree to comply with all city and county renditions and sum lave meting to
building construction, and hereby authodre repocmmuws of this city to enter upon the
rty
above-mentioned cur for
(We) Igoe W ant, indemnify tad keep harmkas the City of C.,mra against
expenses whichmpurposes.
and expenes which may in any waY arose acini aid roily
Ilaconsequenjudgment.orme
senting
of thegreeting of this permit.
A
APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S RCE REGULATION
Re -roofs
Type of Roof
Signs of ApplieuUCentranm Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stored handle Women material
as defined by the Cupertino Municipal Code. Chapter 9.13. and the Health and Safety
Com❑Yes 91 No . Sauna 25537(a)t
All roofs shall be inspected prior to any roofing material being installed.
Will future building
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or occupant um equipment or devices which
i W ardou air commminnls u corned by the Day Area Air Quality Management
all new materials for inspection.
imia?
❑Yes 111No
I ham mad the her mlouss materiae requirements under Chapter h95 of the Celifan
M& Hralmk SsfelyCmdc. Schou 75505,25533 and 2553/.1 understand rest if the building
does not currently hew a mneel that it a my reamvihility to notify the mapant of the
Mqt mounts which no}� mel.pr�ior eeanco of a caurtcam or Occupancy.
Signature Of Applicant Date
f - ?� 3•
All roof coverings to be Class "B" or better
Owner authorized seem
gent Damg