08120024CITY OF,CUPERTINO
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INFORMA` IO;N
BUILDIi.t`DIVISION PERMIT
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BUILDING ADDRESS:
PERMTr NO. '
20875 VALLEY GREEN DR
TBD — TO BE—DF
'
OWNER'S NAME:
PERMrf ISSUE DATE
L28
NE:
A O. CONTROL NO.
ARCHITELTrEPIGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
p .
1 barony allhI ma lia.under pmvisiom W Chepi« 9 (Commacing
m tha cd
with Section 701gB of D;vision Sof de Business and Profesrions; Code, and any Iiccam in
W full to=
RE -RF 5 CARPORTS 5/6,7/8,9/10,11, 3/14&19 CLS A
and CIO
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DaM Cmucmr
128SQ T/O GRVL SURFC BLTUP RF& RPLC W/3PLY GRVL
ARCHITECTS DECLARATION
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SRFCD BLTUP
Lice�iued Pmfcsno 5
OWNER -BUILDER DECLARATION
I botchy affirm that I am mempl from the Contractors Ucansa Law for de
fallowing muco. (Sada. 7030. Bust. and Professman Cadc: Any city or ..any
which ia9uim . permit W construct. WWI. W prove, damolbh, or alai' any suuctum
prior to its issumac. AM require tho applicant for Such permit to fie a signed staWmant
Law
Sq. Ft. Floor Area
Valuation
m,tanieratcadp«an,ffitamapm.;aoneoftho Ca.tmnortLicarm(ChaPW9
(corrmeming with Saxon 7COD) of Division 3 of the Busimai and PmfaximU Code) «
6 4 3 4 5
is mpt Wemfsom and da hub f« de alleged eumption. Any Woladon of
Nat ba exe
APN Number
Occupancy Type
Section 9031.5 by airy applicant far a permit subiecu the appl¢ant to a civil penally Of
rm1 mum than five tundras dollar, (.5003
32609064.00
❑ I. u owner of tW palmy, or my wployce wIN wge a Iba'v role compensadoe,
Required Insr�eCCIODS
will do the wars, and Nc,vucwm b amimmumd of Offered f«saic(See. 7044. Businw
and PoWe,s oro Code: The ConaaCmr, Li2me Law da hat apply W N man Of
l I'
pmpeny who Wilda «imp mmt Woman. and whodoessuchworkhimeelfor through his
awnemplayce, provided Nn such improvements art not;mmnded oroRered forsae. B.
however, the Wilding or improvement Is Said within o« your of campkdon, the owma,
Wilda will have the When of proving that ba did not Wild or improw f« pumom of
sale.).
❑ I. u awror of the property am exclusively contracting with 1MCWaW conucWn W
Contract site project (Sec. 7014. Bushiest and Professions Code:) Tim Cmir WWe3 Li-
cense law d«s.at apply W as owner Of property who Wild, or;mp a. tkmon. and,
who can"=for such project, with • conuacurKs) licensed pursunt W de C.M. cors
Nene law .
❑ l son undo See ,B A P C for this wan
us
Ow. Date
WORKERS COMPENSATION DECLARATION
1 hereby ,Rim under lenity of perjury, onto of the following declaratianss
r hart and will maimain a CcroMaaW of COMMM W .tar-imart for Warkers Compere
'm. as proviMd for by SeNon 3700 Of the LAM Code, for the peA«manC of We
wort for which this per nit b tomos. '
haw and will maintain Worker's Compensation Inssiraiia. u required by Senior
3700 of the Labor Code. f« the pcaarmanco of ft wast f« which this permit b issued.
'
My WOrtera Compcwim Immusb a and Policy namher art:
Calrimr ' pbHry No.: C20a 3371 —,2tx
7
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Crhb seNmneod aot M c«npkad Bthe permit is f««W hundreddoRurs($100)
Car less.)
I casdfy dust in the performaae of the wart for which this permit b issued, I "I not
.
employ anyp:rmn in my manrerm u W h=ome Subject to de WorketY Compensation
-
Laws Of Caifomis. Dai
Appliont
NOTICE TO APPLSCANI: If, Wier making this Cenificam M Exemption, you should
become subject W the W«kctS Comp:nsadon provision of We labor Cade, you muss
r W towith comply with such proviS ans «this pewit shall M deemed mated.
i
CONSTRUCTION LENDING AGENCY
1herebyaffirm that Vert ba loading agency for Ue paaarmanC of
d(Sec. 30
the wort for which this armit b issued (sec. 7097, Civ, C.)
Lenders Nuna
� London Asn....
I «nify that 1 haw red this applicatim and SUM that On Show information b
caneC 1 agme W Comply with W city and county aNimmon and rote laws mlating W
building cons Taction, and hcmby authorise mpresenudvu of this city W enter upon de
17 a Ww-mentioned propeny for Wpection purposes.
(WC) agree to Saw. indammfy and hoop hamlom the City of Cup.'rdno against
n limillde,judgments, costs and expecte which may;n an, Way Keno.&OWA Slid City
> ;n aOnsequence Of tho granting Of this permit.
APPLICANT UNDERSTANDS AND WILL CO PLY WITH ALL NON -POINT
Issued by: Date
-SOURCE REWA SS.
Re -roofs
Type of Roof
Sig,HAZARDOUS MATERIALS DISCLOSURE DaW
Will dW applicuil as Futuro Wilding Ccwmt amus or Handle hasaNau maeria
as defined by the Cupertino Municipal Code. Chapter 9.13. and de Health and Safety
Cade, Saran 25532(.)7
All roofs shall be inspected to any roofing material being installed.
❑Yea
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will Ne applicant or uhac Wilding ,,vont uW e9uiPmmt «davim which
I hvard.0 air conuminnum u darned by Into Bay Area Air Omit, MmSgamam
ikmicE?
all new materials for inspection.
❑Ye No
I hue mad the haurdwu mveria5 aquiamcnuuiderChapierti.95of the Caifor-
MaHel"SemyCode Scrims 7550. 25573 and 25534. I undvsivq Natifde building
J«s iWtama.dy haw a umant. Nu it b my itrniliry W ratify de aecupant of Ne
--oxmiammu hWCOMW eI 'rW US aracmdfica, of occupancy.
Signature of ApplicantDate
All roof coverings to be Class'%¢" or better
0Wnar«mM &—,.Ia Ei Dam