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CITY OF CUPERTINO
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BUILDING DIVISION PERNIIT
BUILDING ADDRESS:
PFRMrr NO.
6 INFINITE LOOP
SOUTH BAY CONSTRUCTIGIST CO
ngngnngg
OWNER'S NAME_
INC
PERMIT ISSUE DATE
PHO
CONTROL NO.
408)379-5500
ARCHI'MCr/ENCTNEER:
BURRING PERMITiNPO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 700M of Division 3 of the Business ar<ftofessions Coda. and my license is
in full force and effect.
3G'
COM' L TI RMV NON—BRNG WALLS, CONCRT CURB, DEMO
License Class Lk 9
Data 7�t —�
EYE
RcHrrEcrS DECL
I understand my plans shall be used as public records
WASH STATION, NEW OVRHEAD DR, NEW CARPET& PAINT,
NEW UPPR & LOWR CABINET, 2860SQ;NO—REF&NO
Lwansed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Ucenae Law for the
STRUCTURL
following reason. (Section 703IS, Business and Professions Code: Any city or county
which requires a permit to conserver, alter improve, demolish, or repair any structure
prior to its issuawe, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's [Jens Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is eumpt therefrom and the basis for the alleged exemption Any violation of
APN Number
Occupancy Type
Section 7031.5 by a" applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SS00).
31602108 . I L 6
❑ L as manor of the property, or my employees with wages as their sole compensation,
Required Inspections
will do Lite work- and the structure Is not intended or offered far sale (Sec. 7044, B usin ss
=m Law
and Professions Code: The contractorss U dons net apply to an owner of
property who builds or improves thermn, and who does such work himself or through his
own a mployces, provided that such imptmemrnu are not intended oroffered for sale. if,
however, the building or improvement is sold within one year of completion, the owner -
builder will ham the burden of proving that he did not build or improve for purpose of
sale.).
❑ L ar owner of the property. am exclusively contracting with licensed contractors to
constnra the project (Sec 7044, Business and Professions Code:) The Contractor's Li.
tense 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 exam pt under Sec. B h P C for this easou
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Canifiute of Consent to self -insure for Wokera 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 Compermulon Insurance, as required by Section
3700 of the Labor Code, for Ne performance of the work for which this permit is issued.
'
My Worker's Compensation Insurance carrier mri Policy num^vS a
e 4 0 S �
Carrier. oli 7C r
CERTIFICATE OF EKEMPnON FROM WORKERS' CzL'tL^j
COMPENSATION INSURANCE
(This section need riot be completed If the permit is for one hundred dollars ($109)
or lets)
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 Califomia Date
Applicant
,
NOTICE TO APPL3CANT. If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec- 3097, Civ. C)
-
Lander's Name
,
Lenrlees Address
1 certify that I have read Nis application and sutra that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby auNorvs representatives of Nis city to enter upon the
above -mentioned propcny for inspeniom purposes
(Wa) agree to save. indemnify and 1¢ep harmless the City of Cupertino agahm
liabilities. Judgments, cops and expenses which may In anyway accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WI 0 Wrni ALL NON -POINT
SOURCE REGULATIONS.
Issued by: Date
Re -roofs
Type of Roof
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
W 11 the applicant or future building occupant pore or handle hazardous material
as defined by the Cupenino Municipal Code. Chapter 9.12. and the Health and Safety
Code, SecUon25532(a)?
[]Yes
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
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.
District?
❑ Yes o
1 have read the houdous materials requirements under Chapter6.95 of site Califor-
niaHcal th & Safety Code, Sccdons25505,?5533 aru125534.1 wet -- panel the if Ne building
don not currently have a tenant, that it's my respmnsibility to notify the occupant of Not
"s°°a whxh m t to' once of a Crnificatc of Oc
Signature of Applicant Date
_09
C / bDate
All roof coverings to be Class'%Q." or better
Owner or authorzCdagcnl
_