08080142 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 3CU1 --TRACT(TR'I1�I+'UR1VI[�TIOAI =
BUILDING ADDRESS: PERMIT NO.
1.0431, N DE ANZA BLVD SOUTH BAY CONSTRUCTION CO 08080142
W NER'S NAME: PERMIT ISSUE DATE
A PPI:,E 170 KNOWLES DR 08/19/2008
ONE: SANITARY NO. CONTROL NO.
(408) 379-5500
ARCHITECT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
0
NT0
uap6 LICENSED CONTRACTOR'S DECLARATION
4 1 hereby affirm that l am licensed under provisions of Chapter 9(commencing Job Description
^ who Senior 100))ofDivision3o(dmBus.andPrufevdomCIo/de.aMmylicenses COMM' L TI ADD 2 OFCS, 5 CLSTS, ADD WALLS, DOORS,
in
it forte and ef! �)/ 7 7
I-keme Cl Us# MECHANICAL & ELECTRICAL
F p Dam Contractor - -
eQQuy� ARCHnECTl DECLARATION
W< 1 undersand my plana shall be used as public records
c LLp t; Licensed Prolessmoul
5 OWNER-BUILDER DECLARATION
F 1 hereby aRm that I am exempt from the Conusames License Law for tM
00 following reason.(Section 70313,Business and Professions Code:Any dry or county
UE! which ruquims a permit las conamect,alcor,improve,demolish,or repair any struseum
priarbiu issuance.alw rtquina the spplinnt for such pcamitm Rk aligned satrment
< this he slicenscJ pursuanuo the provisions oflk Cantncmr's(xxnu law(ch.pmr9 Sq.Ft.Floor Area $75000
Valuation
y�S (commencing with section700o)of Division 3 ofdte Business and Pm(cuions Code)or
y — that he is exempt therefrom and the basis for tis alleged esempdon.Any violation of
Section 7031.5 by arty applicant fee a penult subjects the appl'sa at m a civil penalty of
roem Number Occupancy Type
t mthan BK hundred dollars(350)1. 3 2 6 3 3114 .'V(7'
Q 1,u owner Of the property,army wplayes with wags u Heir sole eompewum,
and da the wort and the ho Comas not rounded a a wrtA apply
an
Businw
and property
who
Csorim te Canuanon.and
who law does rot apply ir an ro uh is Required In$peCL10DS
propertywyabuildsoricepmts thereon,andwM10 doesouchwork hroselrorfassa his
own emPloyaa•provided thatsuehimprowmenuan not inl...n.n oreRelW fasaie.a.
however. have
the aimpm Mvrinaoat edict of youofcaoolefortheawmr-
builds will Nw the Widen of proving loathe did not builtl a improve for purpose of
ale.l.
. Q 1.u owner of the propcnY,sm exclusively contracting with licensed mnuacmrs In
co m uca dte Project(See.7060.Bust.and Professions Code:)The Cootraemrs U.
come law dos not apply to an owner of property who builds or improves demon,and,
who cormsts for such prejecs with a contramr(s)licensed pursuant In the Com acmes
License Law.
Q lamsemptunds See ,B&PCfmdsrtason
ser
Data
WORKERS COMPENSATION DECLARATION
I hemby affirm under penally of perjury one of the following declarWona,
Q Ihaw and w0l mainainaCutifiau ofComentmulf-ivurt for Workers Campem
ation,as provided for by Section 3100 of the Labor Code.for the performance of the
work for which this permit is issued.
Q 1 bave and will maintain Workers Compensation resonance,as mquimd by Smion
31)O of the labor Code.fa the perform.of the work fawhreh this perent ran issued.
My Workers Compewtim Insurance artier and Polity n�urm�ber art:
Cartier.
COW +
No.:`A'((f Q{'1(I(''
FlCATE OF E%FMPITON FROM WORKERS
COMPENSATION INSURANCE
(Thu accom reed not be completed if the permit Is feramhumbred dollars(SIM)
or kis)
I ceerfy,Nm in she performance of the work for which this perms is Wood,I shall net
empty airy penten in any manner an u to become subject to the Worker'Compensation
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT.IL after making Ns Ccniflmw of Exemption,you should
become subject In the workers Compeaadon provsrolu of the Mbar Code,you muss
vJ z forthwith comply with such Proveme,a Nu permit shall be dsmW revoked.
z y CONSTRUCTION LENDING AGENCY
1 hereby Mr.that Nen is a construction knding•gene,for th<perfamance of
C dte work for which dans permit is issued(See.3097,Civ.C.)
6Wi Q Lenders Name
7 z Lenders Add.
U O 1 mdfy that I have rad this applieatim and sum that the.haw in(mmadm ia
U. mnctt 1 some In comply with all city and county ordinances and state laws relating to
0 building com unfan,and hereby amadxe repmuenadves of this city to enter upon the
r W abaw-mentioned property for impemjoa puryoua
(~ n, (we)agree to saw.indemnify and kap hanmleu the City of Cupertino al"
h liabilities,pal cru,casts and cspemcs which many in any way se.agarat said City
U z rn con Ift, granting of Nis Pmy�Is.
APPL A ERSTANDS AND ILL CO LY WITH ALL NON-POINT Issued by: Date 9 (q-
SOU CEREGULATIONS. sV// 6
f os Re-roofs
Sign art pplisndCenvecmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom orhandlc hauNom matedd
u defined by the Cupertino Municipal Cade.Chapter 9.13,and the Health and Safety
�adc. No
on 115121,11)1 All roofs shall be inspected prior to any roofing material being installed.
Ton {t/u,v�
Will mea locant or Nlam Wilding occn nt as If a roof is installed without first obtainingan inspection,I agree to remove
Applicant B W e.An u or device which [3e
NUHCO Nom all contaminants u Jctimd by the Bay Arta Air Quality Managemcnl all new materials for inspection.
QYs 'u
IbIk mad the haratdaua materialrtqurmmensul.lu Chapter G95afine Wiktor-
ora Hcoat&Sato Smamu 25505,25577 and 25536.1 undo dly t oceutp Wilding
dos rot corm he tenant out it' rtaponsibdo,m maty titer aceupant of me
require. hO."berompriur ofa to Sig�reofApplicant Date
nr, gd� �y 8lwg
ownaasPP All roof coverings to be Class'%W'or better