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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMrr NO:
20'105 VALLEY GREEN DR
SOUTH BAY CONSTRUCTION CO
08080157
OWNER'S NAME:
i IN
FERMrr ISSUE DATE
i3R]RG & ASSOCIATES
170 KNOWLES DR
08/21/2008
PHONE:
SANrrARY NO. CONTROL NO.
(408)379-5500
ARCHrrEUIFNGINEFR:
BUIIDING PEP MIT INFO
BLDG ELECT. PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under Provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my liccmt: is
-
in full force and effect fZ
Licensc Q Lk. hh3�6
DEMO I NTR WL S , F LR S r C E I LNG S , L I GH TNG r HVAC &
DR S
Date Contractor smeli
ARCHrrECrS DECLARATION
1 understand my plans shall be used as public meords
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from she Contractor's License Law for the
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
prior to its issuance, also requires tM applicant for such permit to file a signed sutement
that he is licensed pursuant to the previsions of the Contraclars License Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 7000) of Division 3 or cite Business and Proreaians Code) or
$ 2 5 0 0 0 0
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
Number Occupancy
32610046 P Y Type
not more than five hundred dollars (MWo
.'PIN
❑ L as owner of this pmvperty, or my employers with wages as threes sole compertsadon.
will do the tort, and the structure: is not intended or offered for sale (Sec. 70", Business
Required Inspections
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 sale. If,
. however, the building or Inn pruvemenl 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
sak.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code:) The Conuaetors Li-
_
tense Law does not apply to an owner of property who builds or improvesre thereon, and.
who contracts for such projects with a eontracior(s) 0cerued putsuam to the Contractors
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 are of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to elf -insure for WorkersCompen-
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 Workers Compensaion insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued.
'
My Workers ompensadon Inwranc caries and Policy number are:
re:S .g
Carrier. VVkQ K"T1(. Policy No.: ti 3 a -a
CEtfIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
((his section reed not be completed if the permit Is for one hundred dollars ($100)
or less.)
I certify tint 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 Workcn' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after mating this Certificate of Exemption, you should
become subject to the Workers Compensation Previsions or the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the wort for which this permit Is lasted (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
1 certify that I have read this application and state that the above information is
correcL 1 agree to comply with all city and county ordinances and sate laws relating to
building constnetion, and hereby authorize mpresemadvcs of this city to enter upon the
above-mcmioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
IiabititIea, ta,cosU and expenses which may in any way accrue against said City
in consCUARMi6f the granting of this permit.
APPLI ANa NDERSTANDS A Wl COMPLY WITH ALL N- INT
SOUR R ULATIONS,
�u
Issued by: Date �i� O�
-6
Re -roofs
Signake fAopicmuUContracior Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will, the applfUML or fuuucu c building occupant store or handle hamalous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section zs532(a)7
a
❑YeNo
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 haisrthoua air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes �jNo
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
ma Health & Saf Sections 25505, 25533 and 25534.1 understand the if the building
does not a taunt, that It ism risibility to notify the or the
requirements uszbemetprior Ora cacorc cr•
Signature of Applicant Date
Og
' �
roof
All f coverings to be Class " '' or better
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Owner or authorized agent Date