07070108FY OF CUPEKIANO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19748 STEVENS CREEK BLVD
OWNER'S NAME:
SOUTH BAY INVESTMENT GROUP
.SNE:
ARCHITECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Atli Section 7000) of Division 3 of the Business and Professions Code, and my license is
,n full force and effect.
License Class Lic. #
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior m its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for salt (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.). /1
as owner of the pro rty. am exclusively contracting with licensed contractors to
con tact the roject (Se 7044, Business and Professions Code:) The Contractors Li-
cense Law ¢ not appl to an owner of property who builds or improves thereon, and
who can for such p jects with a contractor(s) licensed pursuant to the Contractor's
License
❑ I am e t r B& P r th' reason
Owner Date
O COMPENSATION LARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I hsve and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectio ed not be c pleted if the permit is for one hundred dollars ($ 100)
or less.)
I certiN that in perfo ance f the work for which this permit is issued, I shall n
-- PERMIT'
TBD - TO BE DETERMINED 107070108
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB
Job Description
T.I. FO]t SPECIALTY FOOD STORE. E/M/P OWNER
WAYNE CHANGING ADDRESS FROM 19744 TO 19748
STEVENS
CREEK BLVD.
employ any per in a man come subjec rs' C mpens
Laws of Calif
Applicant
NOTICE TO A PLI NT: If after making this Certificate of lion, no, shout
become subject the Worker' compensation provisions of the Labor Code, yu must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building cons ction, and hereby authorize representatives of this city to enter upon the
above -menti cd property for inspection purposes.
(W agree to MARDOUSMATERIALS
y and keep harmless the City of Cupertino against
liabilities, dgmcnis, nses which may in anyway accrue against said City
in cone nce of thes permit.
APPLI ANTU END WILL =COMPLYWITL ON -P NT
SOU E R � 0-
- ` 1
Sign ofA is tc
MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑
Yes �No
Will the cant or future building occupant use equipment or devices which
emit hazardou ir, ontaminants as defined by the Bay Area Air Quality Management
District?
Y4l JNo
1 ha ad the bazar crus materials requirements under Chapter 6.95 of the Califor-
ria Health Safety C e, S don 25505, 25533 and 25534. I understand that if
c building
deer no an my responsibility to notify the
upant n/cthe
nrior to i ance of a Ccrtifcate (Ff1Ccu
Owner o utho .cd age — G Dec
3q. Ft. Floor Area
369060091JN Number
Issued b,
Re -roofs
Type,of:toof
Valuation
$50000
Occupancy Type
Required Inspections
All roof:, shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signatur-. of Applicant Date
All roof coverings to be Class "B" or better