08090077CITTA" OF CUPERTINU
BUILDING DIVISION PERMIT Ci1�gtACTCiR INEURMATION.
BUILDING ADDRESS: PERMIT NO.
20705 VALLEY GREEN DR SOUTH BAY CONSTRUCTION ED ngoqn077
OWNER'S NAME: INC, PERMIT ISSUE DATE
PHONE: A CONTROL NO.
(408)379-5500
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o o LICENSED CONTRACTOR'S DECLARATION
m --_ 1hereby aliirm4hatIam-liceasedander-provisiormofC_haplcr9(commencing
Z with Section 7000) of Division 3 of the Business and Profrisions Code. and my license is
y in full force and effect�� � Q _S 7 7
j License Class Lic. # l
t•„ Date Contractor
ARCHITECTS DECLARATION
a< 1 understand my plans shall be used as public records
�P.
U. Licensed Professional
n y OW NER•BUILDER DECLARATION
> I hereby affirm that 1 am exempt from the Contractors License Law for the
O O following reason. (Section 703 1.5. Business and Professions Code: Any city or county
<2E which requires a permit to construct. alter, improve, demolish, or repair any structure
n Z r prior to its issuance, also requires the applicant for such permit to Glc a signed statement
< that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
:4 Q
yF- $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y .. 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 (5500).
❑ 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 sale (Sec. 7044, Business
and Professions Code: The Contractors 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 employers, provided that such improvements arc 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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li.
cense Law docs not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec , B & P C for this reason
Job Description
T.I.—REPAIR FIRE DAMAGE,IST&2ND FLR
MODIFICATIONS.
NEW WALLS,CEILING,FLR,DOORS,ELECT/MECH—REROOF 180
SQS. PLUMBING WILL BE DEFERRED.
Ft. Floor Area -
APN Number Occupancy Type
32610046.01
Required Inspections
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers 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:
Carrier. — G�PxPolicy No.: zo
RTfiGFTION -
FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Workeri Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
.J Z forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
E.r rV)i I hereby affirm that there is a construction lending agency for the perfurmancc of
Ri > the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lenders Name
a Z Lender's Address
U 0 I 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 relaying to
Q V building construction, and hereby authorize representatives of this city to enter upon the
U ahove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
r/) liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in corse net of the granting of this permit.
_
UNDERSTANDS AND#ILL COMPLY WITH ALL NON -POINT Issued by:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? ,,��,, tt''
Yes �rvo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
DYcs ONo
I
"
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health& Safety Code. Sections 25505,25533 and 25534.1understand that ifthe building
does not ntly have a tenant that it my responsihility m notify the occupant of the
requirecots whic� must be mel p "'pr ssuanee of Crnifieate of Occuj�anry�
� icy/
Owner or authorized aecnt Date
Re -roofs
Type of Roof
Date �' %� 0 /0%,
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
all new materials for inspection.
Sig ure of Applicant Date
All roof coverings to be Class 'W' or better