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CITY OF CUPERTINO
BUILDING DIVISION PERINUT � ` � � .
Bur 1 ESS: PERMIT NO.
(8 VALLEY GREEN DR SOUTH BAY CONSTRUCTION CO 08050072
OWNER'S NAME: IN C PERMIT ISSUE DATE
APPLE 170 KNOWLES DR 06/17/2008
PHONE: SANrrARY NO. CONTROL NO.
(408)379-5500
ARCHriECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 700D) of Division 3 of the Business and Professions Code, and my license is
m full force and effect
License Cl ✓ f.ic- J!
Dam Contractor
ARCHr1'ECI-S DECLARATION
I understand my plans shah be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's Licensc Law for the
following mason. (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 the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisionsofthe Contractor's License Law (Chapter 9
(commencing with Section 70DD) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ L 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 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 ask 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.)
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the protest (Sec. 7044, Business and Professions Code:) The Contractor's U.
ecrose Caw does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contracror(s) licerued pursuant to the Contractor's
License Caw.
❑ I am exempt under Sec , B & P C for this reason
Owner
Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and w li maintain a Certificate of Consent to self -insure for WorkeesCompen-
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 Workers Compensation )nsurmce, as required by Section
3700 of site Labor Code, for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are- b
Carrier. M.AhPGi-i C. Policy No.: Z 06 01 12-0
LATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (SIOD)
or Icss)
I 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' Compenssation
Laws of California Date
Appllcuu
NOTICE TO APPLICANT: if, alter making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit &hall be deemed revoked.
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.)
Lenders Name
Lenders Address
I certify that I 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 construction, and hereby aothorim representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
liabilities,judgments,cosss and expenses which may in any way accrue against said City
in gelGibpace of the granting of thi
PLICA�NDYEXSTAN72 COMPL WITH ALL NO -POINTsoi,
I di
ntree of ApplitanUCon or etc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Cbaptcr 9.IZ and the Health and Safety
Code. Section 25532(a)?
❑ Yes o
Will the applicant or f turc building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes 0
1 have read the ha7mdous materials requirements under Chapter 6.95 of the Califor-
nia Health & Pafety Code, Scct)onsZ5505.25533and 25534.1understand that lfthe building
does t ty haw a run Char' my responsibility n notify the up of the
rcqui hich must be m 'or issuance of hcsnLc of C cy.
AV
Owner or authori7rd agent Datc
Job Description
RPLC 4 RF TOP HVAC UNTS W/STRCTRL MDFCTNS
-Sq. Ft. Floor Area $ 2 5 0 0 0 0 Valuation
3 2 610 0 4 6 .,bPiN Number
Required Inspections
Issued by:
Re -roofs
Type of Roof
Occupancy Type
Date 67/171-b
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.
PD AAAJ 0',� � S
Signs ure of Applicant Date
All roof coverings to be Class'" or better