09030142CITY OF CUPEKIL O
BUILDING DIVISION PERMIT +1
BUILDING ADDRESS:
20975 VALLEY GREEN DR #289 TBD —
OWNER'S NAME:
PHONE:
ARCHITECT/ENGINEER:
0 p LICENSED CONTRACTOR'S DECLARATION
166
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
7a with Section 7000) ofDivision 3 of the Business and Professions Code, and my license is
W
! le in full force and effect.
i Z License Class Lie. q
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
>wyU
' o ti Licensed Professional
t 0 :1 OWNER -BUILDER DECLARATION
a � I hereby affirm that I am exempt from (he Contractor's License Law for the
:00 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
Z r prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
3 $ (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
not more than rive hundred dollars ($5110).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
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
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 -
buil
d dwill have the burden of proving that he did not build or improve for purpose of
sale .
L 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 contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I a exempt under Sea B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insum Cor Workees 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 pennit is issued.
My Worker's Compensation Insurance carrier and Policy number ate:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foram hundred dollars ($100)
or less.)
I certify that in the performance of the work f r which this permit is issued, I shall not
employ any person in any manner sA , t eco c b' to the Workers' Compensation
Laws of Califoni Dato
Applicant
NOTICE TO APPLICANT: If, after makintihis Certificate of Exemption, you should
become subject to the Worker's Compensation provisions or the Labor Code, you must
Z, forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
—+
Cel
-t 1 hereby affirm that there is a construction lending agency for the performance or
Y, > the work for which this permit is issued (See. 3097, Civ. C.)
it A Lender's Name
jLender's Address
Q 1 certify that I have read this application and state that the above information is
.14 r ' correct. I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction, and hereby authorize representatives or this city to enter upon the
W above-mendoncd property for inspection purposes.
y (We) agree to save, indemnify and keep harmless the City of Cupertino against
y In liabilities, judgments, costs and expenses which may in any way acerae against said City
'T in consequence of the granting of this permit.
A APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NO -POINT
SQURCE REGU TIONS.Q
aw n !..J�- 3 G I coq
Signature of Applicant/Contractor Me
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)?
❑ Yes No
Will the applicant or future building occupant use equipment or device& which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes %61N.
I have mad the hazardous materials requirements under Chapter 6.95 orthe Caiifer-
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
rey '' lemcnis which t be met or to h ua�n/cc of a Certificate of oce7ancy.
IM c m 7u7 !I t�•Ma -1-A Ja � t/7h
Owndr or authorized acent
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
. Ft. Floor Area I Valuation
100
APN Number Occupancy Type
32609041.289
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date 5 , tX , (_)
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class'n" or better
PERMIT NO.
D .
09030142
..
PERMIT ISSUE DATE
S AR
CONTROL NO.
BUILDING PERMITINFO
BLDG
ELECT
PLUMB
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Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
. Ft. Floor Area I Valuation
100
APN Number Occupancy Type
32609041.289
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date 5 , tX , (_)
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class'n" or better