09030116BUILDING DIVISION PERMIT
20975 VALLEY GREEN DR
OWNER'S NAME:
ARCHITECuENGI IEER:
O p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under previsions of Chapter 9 (commencing
Z with Section 7000) of Divisioa 3 of the Business and Professions Code, and my license is
H in full force and effect.
v� Z License Clans Lie. hf
Date Contractor
Iq- ARCHnECi-S DECLARAnON
I a I understand my plan shall be used as public records
t, t- Licensed PmfessionU
t y OWNER -BUILDER DECLARATION
� 72 1 hereby affirm that I am exempt from the Contnators License Law for the
Vfollowing reason. (Section 7031.5, Business and Profcssioes Cade: Any city or county
_ which requires a permit to construct. alter. improve, demolish, or repair any structure
z y prior to its issuance. also mquims the applicant for such permit to fik a signed statement
t - < that he is licensed pursuant to the provisions of the Contractors Mennen Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that be 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 five hundred dollars (SSW).
[11. ss owner of the property, or my employees with wages as their sole compensation.
will do the wodk, and the structure is not Intended or offered forsak (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 employces, provided that such Improvements are not intended or offered for sale. if.
It owever building ox imprevemernl is sold within oro year of opnePletioxt. the owrter-
bu0 L have the huuden of preying that he did not build or improv far purpose of
sale
L sa owner of the properly, w exclusively contracting with Ikensed contractors to
nstruct the project (Sec 7044. Business and Professions Cade.) T1e Conhactoes UJ
«sae Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(3) licensed prvauant to the Conuaaoes
License Law.
❑ I sm�axwpt under Spec 1 �I� B R P C far this n
1 WORKER'S COMPENSATION DECLARATION
1 hereby aff civ under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self -Insure for Warkces 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 wttil maintain Workers Compnmsatlon Insurance, as requited by Section
3700 of the Labor Code, for the performance of the work for which this permit is n... wA
My Worker's Compensation Insurance carrier and Policy number sm:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Ibis section need not be completed lithe permit is for one hundred dollars ($100)
or less)
I oxNfy that in the performance of the work for w'ch this permit is issued.I shall nen
employ any person in any manner so a,
o ce s bj Workers' Compensation
Laws of Califon k
Applicant
NOTICE To APP CANT. If. after making this Certificate of Exemption, you should
beconne subject to the Worker's Compensation psuvisions of the Labor Code, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
y7 ' ' CONSTRUCTION LENDING AGENCY
►�-d I hereby affirm that there is a construction lending agency for the performance of
34 > site work for which Ibis permit Is issued (Sec. 3097, Civ. C.)
Si 0 Lenders Namc
Z Lenders Address
;J Q I ratify that I have read this application and state that the shove information is
comcL 1 agree to comply with all city and county ordinances and state laws relating to
(•" building construction, and hereby authorize representatives of this city to eater upon the
a
above-mentioned property, for inspection purposes
(We) agree to save, indemnify and beep harmless site City of Cupertino against
L, y llabilitles,judg ments.cotsts and expenses which may in airy way accrue against said Qty
;J Z in consegaonce of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITHNON-POINT
SO CE REGUI.A'T1 NS.
Q.:.�� S 6 ori
Sf of ApplianUContractor
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocrnpart stare or handle hazardous mucrial
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)T
[
❑Yes )}'Na
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
District?
Yes EV6
1 have mad the hazardous materials requimmcnts under Chapter 6.95 of t e Califor-
nia Health k Safety Cade, Sections 25505.25533 and 25534. I understand that if the building
does not currently have a rerun[, that it is my responsibility to naify the a of the
requirements which must be mel or to' uanee of a Ccnifcatc of
VVI ,�.(�..�
Own or authorized agent batc
PERMIT NO.
PERMrf ISSUE DATE
S CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
a 0 a
Job Description
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
E/M/P'S-SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Sq. Ft.
32609041.251
Required Inspections
Issued by:
Re -roofs
Type of Roof
Type
Date 5. U ,U `1
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'%." or better