08080050CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.BUILIf~G4'§~ES:& DE ANZA BLVD FLR 1-3 SOUTH BAY CONSTRUCTION CO 08080050
-1.1'11"OWNER'S NAME: PERMIT ISSUE DATE
SAND HILL PROPERTY CO 170 KNOWLES DR 10/02/2008
PHONE: SANITARY NO. COrmtOL NO.
(408)379-5500
ARCHITECTIENGlNEER: BUILDING PERMIT INfO
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tIJ 1= 1 hereby affirm thal I am licensed under provisions of Chapler 9 (commencing ~~ wililSeelion70(0)ofDivbion30flileBusinessandProfessionsCode,andmyliccnseis
::> in. full force and effect. f'> . ~~~Z~i:l~ LleenseQass . h LIC'#_-'::::""';;:J-'-"--'-~-.,f;----
- 0 Dale -i~ ,...., .~l ConlraClor .' D ~:J I ARCHITEcrSDECLARATlON
~ <:5 I understand my plans shall be used as public records
... 1Licensed Professional o~OWNER·BUILDER DECLARATION"' .... I hereby affirm liIal I am exempl from liIe ContraClor's License Law for lhe~~ following reason. (Section 7031.5, Business and ProCessions Code: Any city or counly~!l: which requires a pennit to consl1UCI, alief, rmprovc. demolish., or n:pair any SlJ'Uctun:
TI 3 STORY OFFC INCLUDES ELECT, MECH, PLMB &
STRUCTURAL;NO RE-ROOF-SEE TEMP PERMITS
08070193/08080229 FOR SOME OF THE INSPECTIONS
-", prior lO its issuance, also requires the applicant for such pcnnillo me a signed sLalCmcnl f--------;;:---:;::-=;--7--------,-------~=-:--.,-----t------~~ lhal he is licensed pursuanllo liIe provisions of liIe Contraelur's License Law (Chaplcr9 Sq. Ft. Floor Area $100000 OVjlluation:>:0I-(commencing wilil Section 7(00) of Division 3 of liIe Business and Profc.<Sions C~e) ur Uiii ~-thaI he io exempllhcrefrom and lhe basis for liIe alleged exemplion. Any Yiolalion of l--------.--,:w~T"-;---------t-------':::::-----=--+------
Seclion 7031.5 by any applicant for a permil subjeel> liIe applieanllO a civil penally of ' 32633110 .A-P-l'\I.l\Jumber Occupancy Type
not more liIan five hundred dollars (S5OO). • !""bK~' ';)
o I, as owner of the property. or my employees with wages as their sole compensation,
wiU do the work.. and the SU'Ucture is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The COOIrnC10r'S License Law does nOI apply 10 an owner of
propeny who builds or improves liIercon, and who doessueh work himself Dr through his
awn employees. provided that such improvements are not inLe.nded orofTered for sale. If.
however. lhe building or improvement is sold within one year of completion, the owner·
builder will have the burden of proving liIat he did not build Dr improve for purposc of
sale.).
o t. as owner of me property, am exclusively conlBCling with licensed canlractors to
eonSllUellhe project (Sec. 7044, Business and Professions Code:) The Contraelor's Li
cense Law does nol apply 10 an owner of propcny who builds or improves thereon. and .
who contracts [or such projects with a contractor{s) licensed pursuant lD the ConlraClDr's
License Law. o I am exempt uDder S~ , B &: PC for liIis reason
Owner Date -:-_
---W=O:::R:::K"'ER='S"'C=O""M"::P=E"'N:::S"'ATI=O-::NC:D:::E:::C"'LA-:-="RATION
I hereby affirm under penally of peljury one of lhc following declarations:
o I h;;,\'C and wilt mainULin a Cenificate of ConsenL lo self-insure [or Worker's Compen
salion, as provided for by Section 3700 of liIe Labor Code, for liIe performance of liIe
work: for which this penniL is issued.
o I have and will maint.a.in Worker's Compensation Insurancc. &s required by Section
3700 of lhe Labor Code. for liIe performance of liIe work for which liIis permit is issued.
My Worker's Conwensation Insurance carrier and Policy number arc:
earner: ~.{ " {....-Policy No.: '2cD S -0> li l-v{ Pl
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nol be completed if the permit is for one hundred dollars (Sloo)
or los5.)
I cenif:!, lh::.t in the performance of Lhe work for which this permit is is."ucd. I shaJl not
employ an)· person in any manner so as La become subject to Lhe Workers' CompensationLaws ofCaliforni.. Dale _
Applicant ==-====:-:-:--:_---:-:---:-~:__:_=_-_;_::__-,__--:__,-, NOTICE TO APPUCANT: Ir. arter making liIio Certificate of Exemplion. you sbould
become subjcct La lhe Worker's Compensation provisions of Lhe Labor Code, you must
forthwith comply wilh such pro ...isions or lhis pc:r.mil shaH be deemed revoked.
CONSTRUCTION LENDING AGENCY
I herehy affirm that lhere is a consuuction lending agency for the performance of
the work for which this pennit is issued (Sec. 3097, Civ. C.)Lender's Name _
Lender's Address _
I cen.ify that I have read this application and sLat.e thal the above informatiL>n is
correcL I agree to comply with all cHy and county ordinances and 'slate laws relating to
building consuuction, and hereby authori~ representatives of this City to enler upon the
above-mentioned properly for inspection purposes.
(We) agree lo save, indemnify and lreep harmless liIe City of Cupenino againsl
liabilities. judgments, costs and expc:nsc.s which may in any way accrue against said City ~~e~~:'."'Quenee~~~~~;~"J~J;f.liIiSr-;tL COMPLY WITH AL~L~O~~-OINT
so eE ~.ULATlON: 0 ..•w/ _ (t> 1,./ ""('
FA ~-,-......~ ::>
Sig'ho!vfc"6l""ApplicanliContraelor Date HAZARDOUS MATERlALS DISCLOSURE
Will the applicant or CUlure building oceupanLstore or handle hazardous materiaJ
a.s defined by 1iI. Cupertino Mun,i~ipal Code. Chapter 9.12. and liIe Heallil and Safety
Code, Seelion 25532(a)1 '\. 1"
DYes \.~o
Will the applicant or future building occupant usc equipment or devices which
emit hazardous air conLaminanl.!i as defined by lhe Bay Area Air QuaJiLy Manag:ment
DiSLriCLb Yes ~o
1have read the hu.ardous mat.erials requirements under ChapLcr 6.95 of !.he Califor
nia H.ca~lth&: Safely Code, Seclions 25S05, 25533 and 25534.1 understand lila! iflile building
docs nat n ha~ au:n~ei ~~/J::tsmy rcs!,~~~~~o noufy the occupant of lhe
require en~ ;;~rr;:::::4 i)1:t~cale of Oc(rt;,/~ f
Required Inspections
(~
, CoiJii}
LJ nlfA. ~
Issued by: r~,
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Re-roofs C7
Type of Roof
l /
Date fO "2--(~t
~-'--
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. .
Signature of Applicant Date
All roof coverings to be Class ':If" or better