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CITY OF CUPERTINO
PERMIT
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BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #279TBD
— TO BE D
OWNER'S NAME:
PERMIT ISSUE DATE
BFE'I1IIPt'I' I�Pl
_.ONE:
s CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 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
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
in full force and effect.
License ClassLie.
DateContractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I 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
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
$100
I 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
APN Number
Occupancy Type
not mom than fire hundred dollars (M).
32609041 .279
❑ 1, as 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 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-
will have the burden of proving that he did not build or improve for purpose of
owner of the property, am exclusively contracting with licensed contractors to
znstruct
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 See. B & P C or Nreason
Owner Date
WORKER'S COMPENSATION 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 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)
car less.)
I certify that in the performance of the w�{k for which this permit is issued. I shall not
employ any person in any mann astto bkco1jatiect to the Workers' Compensation
Laws of California. D ` �? ` lJ
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.
j
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. Q
Lender's Name
L-cndees Address
certify that I have ad this application and state that the above information is
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correct I 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
Rliabilities, 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 N -POINT
Issued by: Date E LC , C)
SO RCE REGU ONS.
c-AAAIII�S 6
Re -roofs
Type of P oof
Signature of-Applicant/Contractor D `c
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)?
All roofs shall be inspected prior to any roofing material being installed.
❑yes ONO
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 Area Air Quality Management
all new IT aterials for inspection.
District?
❑ Yes ❑ No
I 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
*
'or
Date
r ircmcn� which rpust be mel to ancc of a Certificate of occu er.
Signature of Applicant
IXI n —�^—� S 6�—def
All roof coverings to be Class'A� ' or better
Owner or authorized agent Da