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CITY OF CUPERTINO
PERMIT
OT -f I
BUILDING DIVISION
BUILDING ADDRESS:
WO ONT REAL ESTATE S ERV IL#5T
NOO 6 0 4 0113
20975 VALLEY GREEN DR
OWNER'S NAME:
PERMIT ISSUE DATE
WOODMONT REAL ESTATE SERVICES
0 16 2006
.JNE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 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 license is
in full force andeffecL
REMODEL EXISTING NON STRUCTURAL RECREATIONAL BL
License Class Lic. 8
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
$40000
which requires a permit to construct, alter. improve. demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
Contractor's License Law (Chapter 9
that he is licensed pursuant to the provisions of the
(commencing with Section 7000) 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 any applicant for a permit subjects the applicant to a civil penalty of
Occupancy Type
not more than five hundred dollars (SSW).
0 I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q p
will do the work and the structure 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 We. If,
sum am%k
FINALK)
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.).
24.' as owner of the property, am exclusively contracting with licensed contractors to
Contractor's Li-
)
d67) l
construct the project (Sec. 7044, Business and Professions Code:) The
b ij
cense 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
License Law.
Li lam w. tun B&PCf this n
ats
am Sir
Owner Date _�
WORKER'S COMPENSA ECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 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 Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
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' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after 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 shall be deemed revoked.
" CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
y the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender'sName
Lender's Address
1 certify that I have read this application and state that the above information is
cortecL 1 agree to comply with all city and county ordinances and state laws relating to
" building construction, and hereby authorize representatives of this city to enter upon the
ahovc-mentioned property for inspection purposes.
4 (We) agree to save, indemnify and keep harmless the City of Cupertino against
P) liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of Ihi rmit.
APPLICANT UND ANDS W1L COMPLY �Ttjri I,L 1/O�N DINT
SOU
Issued by: Date
Re -roof:
Sign pp,eanUCon or Date
HAZARDOUS MA D SCLOSURE
Type of Roof
yP
Will the applicant or future building occ store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
cede, Section 25532(a)?
All roof; shall be inspected prior to any roofing material being installed.
0 Yes t1 ^°
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 hazardous air contaminants as tncd by the Bay Area Air Quality Management
all new materials for inspection.
District?
0 Yes No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not curmndy have that it ' my respo ibility to notify the occ ant of the
L
'ortrance
requireme tsie a acenificato r cup /
Signature of Applicant Date
All roof coverings to be Class B or better
Owner ormorized vent Dare