08100115CITY OF CUPERTINO
DIVISION PERNHT
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BUILDING
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BU"_"T
P08100115
ALLEY GREEN DR
SOUTH BAY CONSTRUCTION CO
OWNER'S NAME:
TNC
PERMIT ISSUE DATE
170 KNOWLES DR
10/20/2008
PHONE:
SANITARY NO, CONTROL NO.
(408)379-5500
ARCHTTECT/ENGINEER
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
Job Description
I hereby affirm that I am licensed under provisier t of (commencing
with Section 7000) of Division 3 of the Bush= a ea®o s C d .jarto my licemc is
C OMM ' L T I r TEMP PERMIT GOOD THRU 11 / 2 0 / 0 8
in full fmce and effect `(
dP
IJcensc Qau Lk:. A
'
Date Contractor
AACHilE DECLARATION
1 undimstand my plans shall be used as public records
Licensed Pmfcsdonal
OWNER -BUILDER DECLARA7ION
I hereby affirm that I am exempt from the Contractors Ucense Law for the
following mason. (Section 703 M. Business and Professions Code: Any city or county
which required a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance- also requires the applicant for such permit to file a Signed =Lcmenl
that he is licensed to the the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions; of
Section 7000) Division 3 of the Business and Professions Code) or
r 10 0 0 0
(commencing with of
That he is exempt therefrom and the basis for the alleged exemption Any vioiadon of
y
3 2 610 0 4 6 Number
Occupancy
parc y Type
Section 7031.5 by A" applicant for a permit subjects the applicant to a civil penalty or
not more than five hundred dollars (SSW).
❑ L is weer of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work. and the structure is not intended or offered for saic (Sec. 7044, Business
and PmfmsWm Code: The Contractors License Law does not apply to an owner of
property who builds or improves themon, and who does such wort 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 riot build or Improve for purpose of
sale.).
❑ L as owner of the property. am exclusively contnWng with licensed rnntraetoss to
construct the project (see. 7044, Business and Professions code:) The contractor's U-
ccnse Law does not apply to an owner of property .who builds or improves !hereon, anti.
who contracts for such projects with a conu-actor(s) licensed purMoL to the Contractors
I.Icenae Law.
❑ I am exempt under Sec B k P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
radon, 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 Station
3700 a the Labor Code, for the performance of the work for which this permit is issued
My Work s Commpensatiom Insurance carrier and Policy nnurnb�er�cas�e:
't
Caricr Policy Nw '= '0) +«ZO
G CATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This .section freed vet be completed if the permit Is for one hundred dollars ($100)
or lets_)
1 crrtify that in the performance of the wort for which this permit is Issued, 1 shall not
employ any person in any manner so is to become Subject to the Workers' Compensation
I.4ws of California Date
Applicant
NOTICE TO APPUCANT: If, after making this Certificate of Exemption, you sbould
become subject Lo the Workcls Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be decmod run"
CONSTRUCTION LENDING AGENCY
I hemby affirm that there is a construction lending agency for the perrormw= of
rho work for which this permit is Asucd (Sec. 3097, Civ. C.)
'
Lenders Name
,
Lender's Address
I certify that I have read this applleulon and stale that the above information is
cored 1 agree to comply with ail city and county ordinances and state laws relating to
building convection, and hereby audnorim mpreseaulives of sus city toenter upon the
above -mentioned property for Inspection purposes
(Wc) agree to Save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
in - oC arc granting of this permit
APP CANT
-roofs
Type of Roof
�° zo
sign ApplianUContractor arm
HAZARDOUS MATERIALS DISCLOSURE
Wlti the applicant or future building occupant store or handle hrnrdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Sccfi�n
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
If a roof is installed without first obtaining an inspection, I agree to remove
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
all new materials for inspection.
District7 �Ny
❑ Yes /----
mad the hu9edoua materials requirements under Chapter 6.95 of the Califor-
25533
or
Signature
iL O
All roof coverings to be Class'.'' or better
Ownermaut6ori>•rdagcnt ,c