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CITY OF CUPERTINO
PERMIT
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BUIL DtNG DIVISION
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #270
TBD - TO BE DETERMINED
OWNER'S NAME:
K(1RFT F(1TTTT1lA'T'T(1TT
PERMIT ISSUE DATE
LONE:
S A CONTROL NO.
ARCHITECT/ENGINEER:
A
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
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
in full force and effect.
License 1-
nu actor
Contr
E/M/P' E -SEE PERMIT #09030198 FOR PLAN CK
D
Dam
ARCHITECT'S DECLARATION
COMMENT S
I understand my plans shall be used as public records
.
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
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
i that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9
(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 or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy Type
not more than five hundred dollars (S500).
32609041 .270
❑ I, as owner of the property, or my employees with wages as their sole compensation,
ns Required Inspections
q P
will do the work and the suwure is not intended or offered for We (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.
ll have the burden or proving that he did not build or improve for purpose of
rLas
wner of theproperty, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
cense Taw 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.
❑ 1 amexempt under See. _ B & P C or th' reason
Owner Date
WORKER'S CO PENSA77ON 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 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.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My Workers 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 anc hundred dollars ($100)
or less.)
I certify that in the performance of thew rk for hick this permit is issued, 1 shall not
employ any person in any manner so m oto su' Workers' Compensation
Laws of Calif, 'a Da
Applicant AIT
NOTICE TO APPLICANT: If, after making this crtificatc 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.)
Lenders Namc
Lenders Address
7
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 sum 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
n 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 NON -POINT
Date
Issued by: J i.P 0
SQURCE REGUL TIONS.
\/� f �V\n..- 51JO
Re -roofs
Sigdature of Applicant/Contractor IDate
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
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
Cade, Section 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
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 V•tvu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth & Safcty Codc, 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
t�rcmcnts whimost x �'f t pri an err^`scam are
.D�
Signature of Applicant Date
• "� `� - �
All roof coverings to be Class "j�" or better
Owner or authorized agent D te