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090301430 Z 2c W a UC wF O tr C nF. V U2 CITY OF CUPERTINO BUILDING DIVISION PERMIT � ITRA Q : NIF BUILDING ADDRESS: PERMIT NO. 20975 VALLEY GREEN DR #290 TBD '0 BE D OWNER'S NAME: PERMIT ISSUE DA'L'E uRET_ T 'I'I�Al .ONE:o S CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I 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 and effect INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES License Class Lic. K DateContractor E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK ARCHITECTS DECLARATION I understand my plans shall be used as public records C OMMENr S . 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 prior to its issuance, also requires the applicant for such permit to file a signed statement Contractor's License Law 9 Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the (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 APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mote than five hundred dollars ($500) 3 2 6 0 9 0 :1 .290 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, ns Required Inspections will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of q P 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 Qr I, as owner of the property, un exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractnes U. cense Law does not apply to an owner of property who builds or improves thereon, and. who contracts for such projects with a contractors) licensed pursuant to the contractor's License Law. ❑ 1 am exempt under Sec jj B & P C or s reason ��\~Date g Owner —WORKER'S COMPENS N DECLARATION 1 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 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: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is foronc hundred dollars ($100) or less.) I certify that in the performance of the wor for w ch this rmit is issued. I shall not employ any person in any manner so c b' Workers' Compensation Laws of 1 a fo ' Applicant 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 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 Namc Lender's Address I certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building convection, and hereby authorize representatives of this city to enter upon am above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against j liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON POINT Issued by: Date S URCE REGU TIONS. Re -roofs Type of Roof Sig atureof Applicant/Comractor I DIU: 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 Cole, Section 25532(x)? .�! Yes �Io All roofs shall be inspected prior to any roofing material being installed. ❑ If a roof i s 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 Area Air Quality Management all new materials for inspection. District? 1]Io ❑ Yes 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 docs not currently have a tenant. that it is my responsibility to notify the occupant or the re utremens wh' must be et pro issuance of a Certificate of Oce cy Signature of Applicant Date 1,e hA_%'t `" 5 G i All roof coverings to be Class'jW' or better Owner or authorized agent ale