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CITY OF CUPERTINO
DIVISION PERMIT�'�I`����fi
BUILDING
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #291
TBD — TO BE DETERMINED -
09030144
OWNER'S NAME:
NORF'TI FCI1TMT)A1PT0N
PERMIT ISSUE DATE
. ctONE:
SAWARyt N6. CONTROL NO.
ARCHIIECT/ENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
.lob Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
orceandIO)ofDivision3ofdteBusincssandProfessionsCode,andmylicenseis
in full force and effect.
infull
License Contractor enscClasa
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
Date ontr
ARCHITECTS DECLARATION
COMMEN S
I 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 Cale: 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
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
$100
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy Type
pe than five hundred dollars (M).
32609041 .2 91
u 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 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-
bu!ild9r will have the burden of proving that he did not build or improve for purpose of
sa
1. as owner of the property. am exclusively contracting with licensed contractors to
construct the pmject (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 comractor(s) licensed pursuant to the Contractor's
License Law.
❑ I amem/p�t under (Sea ^ B & P C for ti n
e Jt.. c X h�^"ti 6 b
Owner F r` ^+ -Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier. 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 thew rk f which this permit is issued, I shall not
employ any person in any manner so bo c s1bg to the Workers' Compensation
Laws of California. D
Applicant
NOTICE TO APPLICANT: If, after making this Ccrificatc of Exemption, you Quid
become subject to the Workces 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 then is a construction lending agency for the performance of
> the work for which this permit is issued (Sec. 3097, Civ. C.)
~ L.endees Name
Lenders Address
I certify that I have read this application and stare that the above information is
correct 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 any way accrue against said City
7 in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date 5 t X .
S?TCE REGULATION .
11
YY1 h..,...� g LL
Re -roofs
Type of Roof
Signature of Applirant/Commictor T�
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous 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
a roof is installed without first obtaining an inspection, I agree to remove
ll the applicant or future building occupant use equipment or devices which
Will
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new rr aterials for inspection.
District?
❑ Yes 04
1 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 currently have a tenant, that it is my responsibility to notify the occupant of the
re uiremcnts whi must be m nor Issuance of a Certificate of Oce pan`'
Signature of Applicant Date
lc- � -r ^ _ , 6Ditc
All roof coverings to be Class'Rj ' or better
Owner or authorized agent