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CITY OF CUPERTINO
PERMIT��
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BUILDING DIVISION
PERMIT NO.
BUILDING ADDRESS:
20975 VALLEY GREEN DR #278
TBD - TO BE DETERMINED
09030132
PERMIT ISSUE DATE
OWNER'S NAME:
vC)nnm-POIZIDATION
S A CONTROL NO.
HONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
fob Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70W) ofDivision 3 ofthe Business and Professions Codcand my license is
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
in full force and effect
License ontractor g
E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK
Date Contractor
D
ARCHHcrsDECLARATION
COMMENT 3 .
1 understand my plans shall be used as public records
i
i 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
�q Ft. Floor Area
Valuation
r prior to its issuance, also requires the applicant for such permit to file a signed statement
9
r that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
3 (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 any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy Type
not more than fire hundred dollars (M).
32609041 .278
❑ 1, 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
Required Inspections
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 arc not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
build improve for of
builder will have the burden of proving that he did not or purpose
sa y
gA✓I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's U.
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 exem t under Sec. . B & P �forshreaton
Owner, Date '? 1
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 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.-
re:Carrier.
CarrierPolicy 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 14c worltror which this permit is issued. I shall not
employ any person in any mantic belin su6icct to the Workcrs' Compensation
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Laws of Calif i i Datc
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Applicant
NOTICE TO AP CAM: if, after making this Certificate of Exemption, you should
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become subject to the Worker's Compensation provisions of the Labor Code, you mast
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
4
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. C.)
Lender's Name
i~ Lcndees Address
0 1 certify that I have read this application and state that the above information is
rl 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
W above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITHAL NON -POINT
Issued by: Date
REGULONS.
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KlbqRe
-roofs
T of F.00f
Type
SigniLure of Applicant/Contractor bate
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, 25532(a)?All
shall be inspected prior to any roofing material being installed.
Section
C] Yes VNo
roofs
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 materials for inspection.
District?
❑Yes EZNo
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
Date
mq�uirem `which m t be met p ' r to 'sats ce of a Certificate of OreJ�'an
Signature of Applicant
11 l A .t^ .l ham- �/ � ` b4
All roof coverings to be Class "W' or better
Owner or authorized agent Liatc