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09030145CITY OF CUPERTINO _ BUILDING DIVISION PERMITd]TG®71`��I�T.. BUILDING ADDRESS: PERMIT NO. 20975 VALLEY GREEN DR #293 TBD - TO BE DETERMINED 09030145 OWNER'S NAME: PERMIT ISSUE DATE 2 9 9 9 PHONE: SAkftAR'f CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMITLNFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES inullforcn7ldCLICfDivision3oftheBusinessandProfcssionsCodc,andmylicenscis in full force and effect. License Class Lic- 8 Contractor , E/M/P' S-SEE PERMIT #09030198 FOR PLAN CK Date ARCHITECTS DECLARATION COMMENTS. I understand my plans shall be used as public records Licensed Professional OWNER-BUILDER DECLARATION 1 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 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 Law 9 i that he is licensed pursuant to the provisions of the Contractor's License (Chapter (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 10 0 1 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Qceupaney Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500), 32609041.293 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, Required Inspections 9 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 docs 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 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. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- 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. ❑ I am exempt under Sea B & P C f this ason Owners )M���� re _A WORKER'S COMPENSA ON DECLARATION I hereby affirm under penally of perjury one of the following declarations: ❑ 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. ❑ 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 arc: Carrier, Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is forone hundred dollars ($100) or less.) I certify that in the performance of the w rk for vhich this permit is issued, l shall not employ any person in any manner so o ecU s 'c thcWorkers'Compensation ia Laws of Califo . Date Applicant -V\ NOTICE TO 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 -Oi 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.) Lender's Name y L.endees Address D I certify that I have read this application and state that the above information is cored. 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 above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against nliabilities, judgments, costs and expenses which may in anyway accrue against said City 7 in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-P INT Issued by: Date JC—Ly, (� SOURCE REGULATIONS. - b Re-roofs _. e of Roof Type Signal of c pplic;NVContractor areT HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hayardous material ' as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? No All roofs shall be inspected prior to any roofing material being installed, ❑Yes N 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 defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes (d No have read the hazardous materials requirements under Chapter 6.95 of the Califow niaHealth &SafclyCodo, Sections 25505,25533and 25534.1understand thatifthe building does not currently have a tenant. that it is my responsibility to notify the occupant of tiro req 're m whit must l proo issuance of a Certificate of tJccupan%'� �bef Signature of Applicant Date -4 All roof coverings to be Class'n" or better Owner or authorized agent oa