08070193U2
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
10495 N DE ANZA BLVD
SOUTH BAY CONSTRUCTION CO
08070193
OWNER'S NAME:
PERMIT ISSUE DATE
SAND HILL/1200 SAN MATEO AVE
170 KNOWLES DR
07/28/2008
PHONEi i
SANITARY NO. CONTROL NO.
(408)379-5500
ARCHrEC'r/ENCINEER:
BUILDING PERMrr 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) ofDi 3 or de Business, andlirofessien, code, andar,y license u
COMM ' L T I TEMP PERMIT GOOD THRU 8 / 2 8 / 8 ;
in full force and effort {{-{ 5 l7
Licence �/ LJc- M
Gas
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following mason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to constrict, aller, hnprove, demolish, or repair any structure
prior to its Lnuarncm, also requires the applicant for such permit to file a signed statement
Aal he is licensed to the the Contractor's uecnse Law (Chapter 9
Sq. Ft. Floor Area Valuation
pursuant provisions or
1 0 0 0 0 0 0
(commencing with Section 7000) of Division 3 of the Business and Professions Codc) or
$
that he is exempt therefrom and the basis for the 94M exemption Any violation of
NNumber
jV(7 '
Occupancy Type
Section 7031.5 by arty applicant for a permR subjects the applicant to a civil penalty or
not more than five hundred dollars ($_50U
3 2 63 3110
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work. and the stnrcture is not intended or offered for sale (Sec. 7044. Business
and Professions 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
own employees, provided that such improvements are not intended or offered for sale If.
however, the building or improsvnent is mid within one yew of completion the owner -
builder will have the linden of proving dust he did not build or improve for purpose of
ask.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
constrict the project (Sec. 7044, Business and Professions Code:) The Contractor's U.
c=w 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
Liceaaa Law.
❑ lam exempt under Sec. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain aCertificate of Consent to self -insure for WorimesCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
wort 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 are:
Cartier. J'V1tAS1� S� C Policy No.: `-t9O ' ( 3 Z
p
C FICA'IE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section Treed not be completed I the permit is for one hundred dollars is 100)
or Less)
I certify that in the performance of the work for which this permit is issued, (shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Lawn of California. Date
Applicant
NOTICE TD APPLICANT: 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
I hereby affum that there is a construction lending agency for the performance of
do 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. 1 agree to comply with all city and cowry ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purpmes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, cops and expenses which may in any way accrue against said City
in consegtrnce of the granting of this permit.
APPLI UNDERSTANDS AND ILL COMPLY WITH ALL ON -POINT
Issued by: Date •S
SO ULATIONS.
Re roofs
Type of Roof
—
Si pp nanUConuiictor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant pore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code. Scaion25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes 94.
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 ha usrdous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? ��y��
Yes ^o
-
❑W
I have read the Waudous materials mquimments under Chapter 6.95 of the Cali for-
nu Health & Safety Crider, Sections 25505, 25533 anif 25534.1 understand that If the building
( -
does not currently have a tenant. that is go responsibility to notify the occupant Of the
mquimme w roues be reel prim ante of a Certificate or
SI ature of Applicant Date
roof coverings to be Class'%" or better
DateAll
Owner dx nrrAagcm