04080064CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
SOUTH BAY CONSTRUCTION CO
fMCI NG04080064
10271 TO
OWNER'S NAME:
PERMITISSUEDATE
CTC FUNDING LLC
511 DIV
NE:
SANITARY NO. CONTROL NO.
(408)379-0400
ARCHITECE ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
Job
I hereby affirm That 1 am licensed under provistoro of Chapter 9 (commencing
wide Section 70018.f Division 3 of the Busin-essand Pmfessiuns Code. and my license is
in fall to. an
REVISION --ASS WASHOUT AREA TO BACK DOOR
.[gft.
License CI a Lic. M
Dam cnnhracto
NO NEW PERMIT ISSUED ORIG. $k03080087
DEC'ARCHITECTS DEC RATION
1 undersond my plana shall be used ss puhlic records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the CnnwcloYs License Law for the
following mason. (Section 713 1.5, Business and Professions Cade: Any city or county
which requires a Permit m construct. alcor, impmm, demolish, or repair any sammum
Prior utits humane., also require, the applicant for such Permit to rile a signed statement
That W is licensed pursuano t to be provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
- Valua"000
(commencing with Section 70YO of Division 3 of be Burmese and Professions Code) ser
that he b exempt therefrom ®d the basis for the alleged exemption. Any violerion of
APN Number
Occupancy Type
Section 7031.5 by airy applicant for a permit subjects the applicant m a civil Penalty of
not mom roan five hundred dollars (5500).
36940017.00 '
F]1, as owner Orion property, in my employees with wages as their sole compensation,-
Required cations
willdod work,andNesnelumisnoLimendedwoRCRdforsale(SC.7044,BusiM6a
and Professions Code: The Cmarecmr's License Law does riot apply m an owner of
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property who buiIdi m improves themon, and who does such work himself or through his
own employers, provided thatsuch impmvemeno ate notinwnded "offered foraale. IL
however. the building or improvement is sold within one year of completion, don owner -
builder will Mve the burden of proving that he did not Wild or improve for purpose of
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nkt.).
❑ 1. as owner of the property, am exclusively contracting with licensed Comments m
construct be project (Sec. 7000, Business and Profms(ons Code:) The Connector's Li
cense Law does not apply to an owner of proper who Wilds or improves ounce, and
who comment for such projects with a.ontmelor(Q licensed Pursuant to the Contractors
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1monense Law.
0 Tem exempt under Sec. ,B&PCfor this mann
_
Owner Dam
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WORKER'S COMPENSATION DECLARATION
1 Wrcby sffirm under penally of perjury one fifth. following dalaralknon
haveand will maintain a Cenificam of Consent to self -insure for Workers Consists-
asprovided for by Seen.. 3700 of the LAM, Cade, for the performance or the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Cod. for the performance of the work for which this permit is issued.
My Worker's Compensation nstrounccarrier and nonhcr Z
(O
yPolicy
Canienj�* UCI l,yWNPO1cNo.:
CERTIFICATE OF EKEMPION FROMW'ORKERS'
COMPENSATION INSURANCE
(This section need not be completed (f Ibe permit is I.,.. hundred dollars (SIMM)
or Was)
I cenify that in the Performance of the work for which Nis Permit is issued, l shall not
employ any person in any manner so as to become subject to the Worker'Compensation
Laws of California- Dale
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption. you should
become subject to the Worker's Compensation previsions of the Labor Code, you must
forthwith comply with such provisions of this Pcomii shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Nem is a construction lending agency for be Performance of
dee work for which this permit is issued (Sec. 3097, Cih, C.)
Lender's Nam.
Lcnder's Add.
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1 certify Nat 1 have mad this application and slow but the shout information is
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comet. 1 agme to comply with all city and county ordinances and sole laws relating to
building construction, and hereby aulorie mpoommun a of this city to enter upon be
above-mentioned property for inspection purposes.
(We) agrtt to save, indemnify and keep harmless the City of Cupeniao against
j Ilabilide6judgmeno, costs and expenses which may many way aceto, against aid City
in consequence of granting of this Permit.
APPL14 NT UNDERSTA AND WILL COMPLY Wlrry ALL NON -POINT
Issued by: Da f
souR� ypT� Q /2'/�
Re -roofs
Type Of Roof
JN�s�� q
Lam"
Signa Applicarmcou actor Dam
NAZAI DOUS MATERIALS DISCLOSURE
Will be applicant or future building occupant store or handle havardous mawdal
as defined by the Cupenimo Municipal Code, Chapter 9.12. and the Health and Safety
Code, Schon 25532(a)?
C] Yes �No
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
Will the applicant or future building occupnm use equipment or device, which
hmardoua air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
net?
❑Yes jdNu
I have mad be haaaNnus materials requirements underchapterfi.95 of tW Califor.
rise Fical &Safely Cade, Sections 25505,25537 and25534.1 undersmnd NmifNe Wilding
does mol rrcnsly M1asxa ten i,Net it is my repimsibuily m ounfy be occupant of be
reyuimmcn 'cnya�lx:avanceorace .jda,".upncx
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Signature of Applicant Date
u[ �j /aq
All roof coverings to be Class "B" or better
owner eriacdagent Dine