07090139BUILDING DIVISION PERMIT
""DTMr STEVENS CREEK BLVD
R'S NAME:
SOUTH BAY INVESTMENT GROUP
PHONE:
ARCHnECT/ENGINEER:
p ZO LICENSED CONTRACTOR'S DECLARATION
Vr- 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z w with Section 70(1(1) of Division 3 of the Business and Professions Code. and my license is
a„ in full force and effect.
t ? License Class Lic. #
p Date Contractor
F vt ARCHITECTS DECLARATION
7 a..t
< I understand my plans shall be used as public records
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u. y Licensed Professional
O < OWNER -BUILDER DECLARATION
a1 hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason. (Section 7031.5, Business and Professions Cate: Any city or county
< which requires a permit to construct, alter, improve, demolish, or repair any structure
w prior to its issuance. also requires the applicant for such permit to file a signed statement
- ? < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
t= C (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
U 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 (5500).
[, 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
andProfessions 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
awn emptoyces, provided that such improvements are not intended or offered for sale. If,
however, Ute building or improvement is sold within one year of completion, the owner-
iiiit
have the burden of proving that he did not build or improve for purpose of
of the property, am exclusively contracting with licensed contractors to
ppmje Sec. 7044, Business and Professions Code:) The ContractoesLi-
" oes not pply to an owner of property who builds or improves thereon. and
ts f s projects with a contractor(s) licensed pursuant to the Contractor's
.e B& PC
for U1ia reason
Date `
ORKER'S COMPENSATION DECLARATION
II hereby affirm under penalty of perjury one of the following declarations:
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0 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.
0 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:
Carrier. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Lion ed not be completed if the permit is for one hundred dollars ($ 100)
or less.)
1 certify that n the rforman a work for which this permit is issued,) shall not
employ any in4y n er come subject to the Worke ' Compe tion
Laws of Cali o i
Applicant
NOTICE PLI r make is CcnirL to of Excmp n, u shoo
become subje to the Worker's Compensation provisions of the Labor Code, you must
forthwith comp with such provisions or this per
shall he deemed revoked.
PERMIT NO.
TBD - TO BE DETERMINED 07090139
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
Job Description
REVISION -KITCHEN LINE LAYOUT
ORIG #0"7070108
Ft. Floor Area
3690600IWWNumber
CONSTRUCTION LENDING AGENCY
I 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.)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building cons ction, and hereby authorize representatives of this city to enter upon the
above -men ed property for inspection purposes.
( agree to save, indemnify and keep harmless the City of Cupertino against
liabiliLio, jhdgmcnts. c sts and expenses which may in any way accrue against said City
in co c of the ranting of this permit.
APPJdANT)INDFAsTANDS AND WILL COMPLY WITH ALLAN -POINT Issued by
- HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
lcImcd by the Cupertino Munici odc, Chapter 9.12. and the Health and Safety
1c, Section 25532(a)?
0Yes No
Will the applicant or future build, occupant use equipment or devices which
emit hazardous air contaminants as ed by the Bay Area Air Quality Management
District?
0 Yes o
I ha ad the haza oto materials requirements under Chapter 6.95 of the Califor-
nia Heal lh afcty Codc, tions 25505, 25533 and 25534.1 understand that if the building
does not rend have t, that it is my responsibility to noul'Y the pant of the
.,...... m/� t n issuance of a Certificate oflpcfu /
authorized
Re -roofs
Type of Roof
BLDG
$0
Type
Required Inspections
............v %
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