06090142 CITY OF CUPERTINO
BUILDING DIVISION pER1VIIT
a
BUILDING ADDRESS: SOUTH BAY CONSTRUCTION CO Pf06090142
10400 RIDGE VIEW CT
OWNER'S NAME:
PERMTT ISSUE DATE
APPLE 170 KNOWLE
)NE: SANITARY NO. CONTROL NO.
(408).379-5500
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG EQ PLUMB MO
O p LICENSED CONTRACTOR'S DECLARATION
U f= I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z U with Section 7000)of Di '' n 3 of the Business and Professions Code,and my license is
y in full force and effect. ?� T. I . -8901 ADD CONFERENCE RM, STORAGE RM, LAB
Date Contractor
s Co # T-BAR CEILING, FLOORING, DOORS-1ST FLOOR
t,,,� Date Contractor -
ARC all be used
DECLARA oN NO EXT IMPROVEMENT EXCEPT FOR H/C
�U 1 understand my plans shall he used as public records
,a
o H Licensed Professional
OWNER-BUILDER DECLARATION
3< 1 hereby affirm that!am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
m which requires a permit to construct,alter,improve,demolish,or repair any structure
Z} prior to its issuance,also requires the applicant for such permit to file a signed statement
=C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
F (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 $132316
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
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 31606046 . 00Required Inspections
and Professions Code:The Contractor's License Law dors not apply to an owner of q p
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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does 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.
❑1 am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
L]1 have 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 Worker's 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. Ltaeo-,,CrJ Aµ{ti�;C��oGcy1Q"o.: 051 ZZZ-12
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be compacted if the permit is for one hundred dollars($100)
or less.)
1 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 Workers'Compensation
Laws of California.Date
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.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
a the work for which this permit is issued(Sec.3097,Civ.C.)
a,Q Lender's Name
0Lenders Address
U C—) 1 certify that I have read this application and state that the above information is
w►" correct.1 agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction,and hereby authome representatives of this city to enter upon the
W ahovc-mentioned property for inspection purposes.
(We)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
U Z in consequence of the granting of this permit.
r" ANT UNDERSTA S A WILL COMPLY WITH ALL NON-POINT Issued by: Date —GG
OURCE REGULATIONS e
Re-roofs
-
-
aturc of Applicant/Contractor Datc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
I have read the hazardous materials requirements under chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does rrentI have a tenon it i y m3ponsi ility to notify the occupant of the
re u m is which must be me ri ranee or ertificate or occ ant y. Signature of Applicant Date
�.cd a� i o °-o 6 All roof coverings to be Class"B"or better
Owner or authorized agent Date