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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #247
TBD — TO BE DETERMINED
OWNER'S NAME.
PERMrr ISSUE DATE
PHONE:
SXRffAftY46. CONTROL NO.
ARC Hri'ECr/ENCLNEFR:
BUILDING PERMrrINr-O
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I me licensed under provisions of Chapter 9 (commencing
with Section 74011) or Division 3 of the Business and-Proiculmms Code, and my license is
in full force and efrem
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
LicDante cse Class - coonrractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHrrECI-S DECLARATION
I understand my plana 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 70313, Business and Professions Code: Any city or county
which requires a permit to convect. alter. improve, demolish. or repair any structure
prior to its issuance, also requires Wo applicant for such permit to file a signed statement
that he is licensed pursuant to the previsions of We Comractmrs License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 or to Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation or
$100
APN Number
Oe
eeu Pane Y TYP
Section 703 )3 by any applicant for a permit subjects the applicant to a civil penalty of
not mors tan five hundred dollars ( WIL
32609041 .247
C]L as owner of the property, or my aopkryces 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 cod—_ The Contractors Liccrw Law dors not apply to an owner of
property who bullas or improves thereon, and who does such wort himself or through bis
own employees, provided that such improvements ase not intended or offered for sale If,
however, the building or improvement is sold within one year of completion, the owner-
bullwill have the buds of proving that he cid not bald or impmn for purpose of
7ss L as owner of the property. am exclusively contracting with Licensed comracmrs to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
ccnse Law does not apply to an owner of property wbo builds or improves thenton. an cl .
who contracts for such pmjeeta with a contractor(s) licensed pursuant to tie Contractors
License Law.
❑ I am pt under Sec B R P C for a
Ownher 5
WORKER'S COMPENSATION DECLARATION
I hereby a1T1nm under penalty of perjury ane of the following declarations:
❑ I have and will maintain a CertlBcate of Consent to self-huure for Walsers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit Is Lamed.
❑ I have and will maintain Warkc s Canpmu&tlon Insurance. as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is lasered
My Workers Compensation hu franc: carrier and Policy nunber are:
carrier. Policy No.:
CERTBICATE OP E MMP 7ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed Ir the permit is forone hundred dollars ($100)
or less.)
I certify that In the penformarca of the work for w ch this omit is ismcd, l shall not
employ any person in any manner so as to beer s b t t kers' Compensation
Laws of California D
AppLicant A es
NOTICE TO APPLIcA$rr. if, alter making ihis Cent rate of Exemption, you should
become subject to the Workers Compensation provisions of the Libor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Were is a congnrction lending agency for the performs= or
the work for which this permit is issued (Sac. 3097, Civ. C)
Lenders Name
benders Address
I certify that I have end this application and sate that the above information is
correct I agree to comply with all city and county ordinances and sate laws relating to
building construction, and bemby authoria reptaenwives of this city to enter upon the
above-mandoned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino &14031
liabilitlea, Judgments, costs and expert which may in any way acme against said City
In consequence of the granting of this PermiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N -POINT
Issued by: Date Ct
SOURCE REGULATIONS.
6 b
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Re -roofs
Type of Roof
Sigritaure of AppiiaeUContractor Eftle—
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuuuo building Occupant. sure or handle hazardous material
as defiled by the Cupertino Municipal Code, Chapter 9.12, and to Health and Safety
Code Section 25532(°)7BN/o
Yes
All roofs shall be inspected prior to any roofing material being installed.
[I
If a roof is installed without first obtaining an inspection, I agree to remove
Will We applicant or future building occupant use equipment or devices which
emit harindous air contaminants as defied by to Bay Area Air Quality Management
all new materials for inspection.
Dishict7
❑ Yrs No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Secdons 25505.25533 and 25534.1 understand that If ter building
don not currently have a umant, that It is my responsibility to notify the occupant or rhe
irenllents which m be met r to' Of Cettifcae ear �°
I
Signature of Applicant Date
' '
All roof coverings to be Class " " or better
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Owner or wthonind agent