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09030155az cc IUE ;zw =11 05, I�C �F•'LL i a ta.0 U. v 0 1<C :ma h.z`> AHC CITY OF CUPERTINO PERMIT ; BUILDING DIVISION BUILDING ADDRESS: PERMIT NO. 20990 VALLEY GREEN DR #646 TBD - TO BE DETERMINED 09030155. OWNER'S NAME: PERMrr ISSUE DATE PHONE: SA R CONTROL NO, ARCHITECT/ENGINEER: BUILDING PERMirlNFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing inSection 7000) eandeffecL vision3oftheBusincssandProfcssiunsCode,andmyliccnseis in full force and effect. INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES License Lic. Dale Contractor lr E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK ARCHITECTS DECLARATION I understand my plans shall be used as public records COMMENTS. Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors 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 that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 Sq. Ft, Floor Area Valuation (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 net more than rive hundred dollars (s500). 32609053.646 0 I, as owner of the property, or my employees with wages as their sole compensation, 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 sate. 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- ccase 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 Contractors License Law. ❑ I am exempt under Sea B & PSC for this reason Owner f or.-� � V,— Date J 1 b 1 1J 1 V WORKER'S COMPENSATION DECLARATION ` I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self -insure for Workers 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 arc: 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 the work for which this permit is issued, I shall not employ any person in any manner pas h rntubjecl ttrthc Workcrs' Compensation "l b lJ Laws of California. Date 7 1 1 Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. I 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.) Lenders Name Lenders Address I certify that I 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 construction, and hereby authorim 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 I liabilities,judgments, costs and expenses which may in any way accrue against said City 225 in consequence of the granting of this permit APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT /t Issued by: Date SOU CE REGULATIONS. 1 -- f.1.1�..-.. A �y�-�--�- S l�� Re -roofs _. Type of Roof Signature of Applicant/Contractor Da HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant stare or handle hayardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely Code, Section 25532(a)? No All roofs shall be inspected prior to any roofing material being installed. El Yes LJ If 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 emir hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for Inspection. District? ❑ Yes No 1 have read the ha7anlous materials requirements underChapter 6.95 orthe Califor- nia Health & SafetyCodc, 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 dor to issu_zqance of a Certificate of Oc`pan mquireme is which must be melp Signature of Applicant Date �'"`""-- F ��� All roof coverings to be Class "`` or better ' Owner or authorized agent D lc '