09030105BUILDING DIVISION PERNUT
OWNER'S NAME.
ARCHTTECTIENGINEER:
109 p LICENSED CON IRACMS DECLARATION
v 1 hereby affirm that 1 am Ikensed under provisions of Chapter 9 (commencing
Z with Section 7000) of DivMon 3 of the Bum and Professions Code, and my ho nscis-
�< H in full force and offett
r Z License Class Lie. 0
Date Contractor
ARCHnwrs DECLARATION
I understand my plans shall be used as public records
5
Licensed Professional
s y OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's license Law for the
yp Opr following mason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improvc demolish, or repair any structure
e y prior to its issuawr alsorequires 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 Code) or
e that he is exempt rhemfrom and the basis res the alleged esempdon. Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a Cavil penalty of
not more than five hundred dollars (S500).
❑ L as owner of the property, or my employees with wages as their sok compensatlat,
will do the work, and the structure Is riot intended or offered for sok (Sec 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such wort himself a through his
oven employees, provided that such improvements ate not intended or offered for sale. If.
however, the building or improvement is sold within one year of completion. the owner -
buil have the burden of proving that he did not build or Improve for p apos of
L u ovrnner of the property, am exclusively contracting with licensed C:antracters to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li.
cense Law does nix apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed prmwam to the contactors
License Law.
❑ l am exempt under Sec B h P C for
Owner 11_1jIA A I- - -AJ)._-
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following Cledaarions:
❑ 1 have and will maintain a Canilicare of Consent to self -h asurc for Workers Compen-
sation. u 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 Waters Compasaton lnauance, u required by Section
3700 of the Labor Code, for the per(amance of the work for which this permit Is issrcd
My Workers Compensation Insurance Carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF MP7MP 7ON FROM WORKERS
COMPENSATION INSURANCE
Cries sabimn need not be completed tribe permit Is forone hundred dollars (S 100)
or less)
I cattily that in the performance of the worli for a ch this permit is issued. I shall not
employ arty person in any maoner soue o s je Workus' Compensation
ws
Laof California. Date
Appal—,
NOTICE TO APPLICANT: if, after mating this Certificate of Exemption, you shouff
become subject to the Workers Compensation provisions of the Labor Code, you must
,J O forthwith comply with such provisions or this peanit shall be droned revoked.
CONSTRUCTION LENDING AGENCY
r�r 1 hereby "Tum these there la . construction lending agency for the performance of
pre> the work for which this permit is issued (Sec. 3097, Civ. C)
W 0 Undoes Nam1 Lenders Address
U O 1 certify that I have rad this application and sue that the above informaton Is
V. `' ` conecL l agree to comply with all city and county ordinances and state laws relating to
Op building construction, and hereby archaize repraaativa of this city to Cara upon the
v above-mendoned pmpcny for inspection purposes
' a (We) agree to save, indemnify and keep humless the City or Cupertino against
h..0 Cn liabilities, judgrocnts. comas and expenses which may In any way acrnhe against said Qty
U r,,7- in consequence of the granting of this penhll.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH NON -POINT
sRvRCE RE MONS. I 6 Ci
Siggkum of AppdianoContracmr oto
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant acre or handle hazardous material
as dellned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(1)7
❑ Yes 01
Will the appliam or future building occupant use equipment or devices which
emit haardous air contaminants as defined by the Bay Area Air Quality Management
District? /
❑ Yes 6A
1 have read the haardous materials requimments under Chapter ii.95of to Ctdifor-
nia Health & SafctyCode, Sxtona 25505, 25533 and 73534.1 wdcsaand dam if the building
does not currently have a ==L. than it is my responsibility to notify the oecupan of to
rcqui� Ls vXldch mtat�e mel prie�o Lssuppce of a Certificate of fkRupl, . j
rrAmi 1 nu.
PElUar ISSUE DATE
CONTROL NO.
BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Ft. Floor Area
Valuation
APN Number Occupancy Type
32609041.242
Required Inspections
Issued by:'1Lm
Re -roofs
Type of Roof
Date 5 . Le . o ct
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 "A" or better