09030100;
CITY OF CUPERTINO,
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #222
TBD — TO BE DETERMINED
09n,3ninn
OWNER'S NAME.
PERMIT MSUE DATE
PHONE.
S A CONTROL NO.
ARCHnEC17ENGINEER:
BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
ucEisis D CONTRACTOR'S DECLARA71ON
I hereby affirm that I sm Ikensod under provisions of Chapter 9 (commencing
Job Description
Section 7 Division 3����aa�� a��my�=a
�
full force and�efrect.
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
License Class
Dam Contracons or
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
--
ARCHTTEcrS DECLARATION
I understand my plana shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors Litems Caw for the
Following reason. (Section 70313. Business and Professions Code: Any city or county
which requires a permit to construct. alter, improve, demolish, or repair any structure
prior to its issuance also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractors Licenser Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70D0) of Division 3 of the Business and Processions Cade) or
that be is exempt therefrom and the basis for the alleged exemption. Any violation of
$100
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy
not more dollars5001.
an five hundred dors (&Type
32609041.222
❑ 1, as owner of the property, or my employee with wages as their sole compensation,
Will do the work, and the structure Is not imended or offered for sale (Sec. 7044, Business
Required Inspections
and Profession Code: The Contractor's I ksnse Law does not apply to an owner of
property who builds or improves thercon, and who does such wort himself or through his
own employees, provided that such improvements are not intended or offered for sale If,
however. We building or improvement Is sold within one year of completion, die owner -
builder will have the harden of Keying that he did not build or improve for purpose of
K. the licensed to
C owner of property, w exclusively contracting with contractors
coonarnct We project (Sec. 7044. Business and Professions Code:) The Contractors L.6
cense Law does not apply to an owner of property who builds or improves thereon. and.
who contracts for such pmjmca with a coms2ctor(s) licensed pursuant to the Contraemrs
License Law.
❑ 1 am exempt under Sec. Btq& P for rraon
Owner / .v/I/yl - l I�il� DaW
WORKERS COMMENSATION DECIARA770N
I hereby affirm under penalty of perjury one of the following dedatationt
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compen.
sadon, 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 Workers Compenaation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit Is Issued
My Workers Compensation futurancer artier and Policy number are.
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Th[s section need not be completed if the permit is for one hundred dollars (& 1011)
or less.)
I certify that in the performance of the work for whk#i this permit is issued. I shall not
employ any person in any manner so AS ser Wortm r e Compensation
Laws of California Date
Applicant
NOTICE TO APPLICANT: If. after m ng this Certificate of Exemption, you should
became subject to the Worlsrs Compensation provisions of the Labor code, you must
forthwith comply with such provisions or this permit shall be domed mvoite
CONSTRUCTION LENDING AGENCY
I herby afrrm that them is a construction Lending agency for the performance of
the work for which this permit Is issued (Sec- 3097, Civ. C)
-
Lenders Name
'
Lenders Address
I certify that I have read this application and argue that the above information is
coram l agree to comply with all city and county ordinances and ante im relating to
building construction, and hereby authorize represenudves of this city to enter upon the
above -me doped property for inspection purposes
(Wer) agree to save, indemnify and keep harmless We City of Cupertino against
liabilities, judgments, coati and expenses which may in any way scene against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- INT
h
Issued by: Date r V
V
SO CE Uu����ONS
A�.c�. � %ZA S�6
Re -roofs
Signature of Applicant/Conraclar D&
HAZARDOUS MATERIALS DISCLOSURE
-
Type of Roof
Wail the applicant or future building oavpant stone or handle haande us material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Station 25532(a)?_CHfI/o
Ya
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
Will tic applicant or future building occupant Use equipment or devices which
cmii hazardous air cond•minan n fined by the Bay area Air Quality Management
District?
all new materials for inspection.
❑Yos o
I have read the haraMeuts nnmsterisk requirements under Chapter 6.95 of the Califor-
nia Hcalth & SafctyCodc, Sedans 25505, 25533 and 25534.1 urdeuand Wstif de building
does riot currently have a tenant. that it is my responsibility to notify the ocve wi of the
requirements which mint met pro
e rasa I Certificate ter
Signature of Applicant Date
g 64
ass
All roof coverings to be Cln�3.a' or better
/"T
Owner or authorized agent Dag