06090143BUILDING DIVISION PERMIT
BUILDING ADDRESS:
SOUTH BAY CONSTRUCTION CO171WF '06090143
OWNER'S NAME: PERMIT ISSUE DATE
APPLE 170 KNO
PHONE:
SANITARY NO, CCNTROL NO,
ARCHITECT/ENGINEER:
W a LICENSED CONTRACTOR'S DECLARATION
U f= I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
i a a with Section 7000) of Div�n 3 of the Business and Professions Code, and my license is
e, in full force and effect. '�' 7
t r� � License Cl s Lic. ri
F„. Date '� Contractor .
ARCHITECTS DECLARATION•
C < I understand my plans shall be used as public records
)WU
a F- Licensed Professional
tQH
OWNER -BUILDER DECLARATION
jag 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
C 0 following mason. (Section 703 1.5, Business and Professions Code: Any city or county
m which requires a permit to construct, alter, improve, demolish, or repair any structure
Z y prior to 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
Fz (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
r3 — 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 sale (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 property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner mf property who builds or improves themon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractofs
License Law.
❑ I am exempt under Sec. , B St P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:.
❑ 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.
❑ 1 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 Worker's Compensation Insurance carrier and Policy number am:
Cartier. C 1 lvYl l d' u,^f o icy No.:
CERTIFICATE OF EXEMPTION FROM WO R '
COMPENSATION INSURANCE
(This section need nothe completed if the permit is for one hundred dollars ($100)
or less.)
I certify the-. 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, alter making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z rA CONSTRUCTION LENDING AGENCY
H r.. I hereby affirm that there is a construction lending agency for the performance of
LY+ , the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lender's Name
p" Lender's Address
�z
U O 1 certify that 1 have read this application and state that the above information is
V. '—' correct. I agree to comply with all city and county ordinances and state laws relating to
0 building construction, and hereby authorise represcnrativcs of this city to enter upon the
U above-mentioned property for inspection purposes.
L1. (We) agree to save, indemnify and keep harmless the City of Cupertino against
H In liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in cc qu cc of the granting of this permit.
AP LICA T UNDERSTANDS N ILL COMPLY WITH ALL NON -POINT
S1 URCE�G'ULATIONS. ., ff
Signature of Applicant/Coiftractor Date
HAZARDOUS 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 Safely
Code, Section 25532(a)? '
❑ Yes Na
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District? �1
E] Yes K1No
1 have read the hazardo
us
``materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs 99 cu mly have a tenant, that it is my responsibility to notify the occupant of the
mq1mmc which must be met pti u issuance of a Certificate of Occupancy.
'L�-r—�orizcd aCcnt Dale
"MINIMM
Job Description
BUILDING PERMIT INFO
ELECT PLUMB
T.I.-2,990' ADD CONFERENCE RM/LABS, T -BAR
CEILING, FLOOR, DOORS -1ST FLOOR
Sq. Ft. Floor Area
APN Number
31606046.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
ValO90716 3
Type
Date 1e:)' -1p—&/4
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 "B" or better