08070103CTTY,OF CUPEKfIN0
BUILDING DIVISION PEPUMT
Bu1LIjlTMF.Rs_ DE ANZA BLVD
PERMIT NO.
SOUTH BAY CONSTRUCTION CO 08070103
OWNER'S NAME:
11v ,. PERbdrr ISSUE DATE
SAND HILL/1200 SAN MATEO AVE 170 KNOWLES DR 07/15/2008
ARCHITECT/ENGINEER:
4 O p LICENSED CONTRACTOR'S DECLARATION
U F I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z W with Section 7000) of Div' 'on 3 of the Business and Professions Code, and my license is
n y in full farce and effect Z
j ? License Class•
y in Date Contractor
ARCHITECTS DECLARATION
aa 1 understand my plans shall be used as public records
)yd
y O y Licensed Professional
W1 g OWNER -BUILDER DECLARATION
1 hereby arm that I am exempt from the Contractors License Law for the
0 O affirm
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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 file a signed statement
= a that he is licensed pursuant to the provisions of the Contracwr's License Law (Chapter 9
Yt– (commencing with Section 7000) of Division 3 of the Businetsand Professions Code) 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 mom than five hundred dollars (5500}
❑ 1, as owner of the property, or my employees with wages as their sok compensation,
will do the work and the swcture is not intended or offered forsale (Sec. 7044, Business
and Professions Code: The Contractors 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 salt 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 Contractors U.
cease law does not apply to an owner of property who builds or improves thereon• and
who contracts for such projects with a eontnctor(s) licensed pursuant to the Contractors
License law.
❑ 1 am exempt under Sec , B & P C for this mason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I 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 Compcn-
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 Worke�es�A(Compensation Insurance carrier and Policy OF EXEMP ?mber are: t
Cartier. 41ik-1.�SICATEL_ �-` PolicyNo.: "Z GetB3 2'1?
RTIFION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far ane hundred dollars ($100)
nr leu)
I certify that in the performance of the work for which this permit is issued. 1 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 Workces Compensation provisions of the Labor Code, you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
F -r 1 hereby affirm that there is a rnnsuuctinn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
aQ Lenders Name
Z L.endeesAddmss
U Q 1 certify that 1 have read this application and state that the above information is
LL. — correct. 1 agree to comply with all city and county ordinances and state laws relating to
OV building construction. and hereby authorize representatives of this city to enter upon the
shove -mentioned property for inspection purposes.
Ha (We) agree to save, indemnify and keep harmless the City of Cupertino against
�y
CA) liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in conaeq e f the granting of this rmit.
►� APPL! UNDERSTANDS Np WILL COMPLY WITH ALL NON -POINT
SOU REGU ATIONS. /
Sign pplicanUConttactor Dam ~
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 Safety
Code, Section 25532(a)?
C] yes o
Will the applicant or fu urc building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District7
❑ Yes 0No
1 have mad the hazanloas materials requirements under Chapter 6.95 of the Califor-
nia Health & Sall, ode. Sections 25505.25533 and 25534.1 understand that if the building
docs not c ndy h vc a tenant. that it is y r nstbitity m notify occupant of the
requirem is whic test be met pri trance of ficate of capon
/1170
0
Owner or au or(zad agent Date
SANFIAKY NO. CONTROL NO.
(408)379-5500
Job Description
DEMO INTER WLS& CEILNGS& DOORS
Ft. Floor Area
3 2 6 3 3110 : Number
Issued by:
Re -roofs
Type of Roof
$20000
Required Inspections
BUILDING PERMIT INFO
ELECT PLUMB MECH
Uccupancy Type
Date
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". ' or better