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CITY OF CUPERTINO
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BUILDING DIVISION PERNHT
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BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #200
TBD - TO BE DETERMINED
n9ni0087
OWNER'S NAME.
PERMIT ISSUE DATE
PHONE
S CONTROL NO.
ARCiirIECI'lENGiNF.IIt:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licen under provisions of Chapter 9 (commencing
with Section 70DO) vtslom3otthe 8uourssanelRofesawnsCoda, and myinconmis
nfulllfforceandeRat
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
Date cortuma r
E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK
ARCHITECT'S DECLARATION
I understand my plaits "I be used as public records
COMMENTS.
Licensed Profesatanal
OWNER -BUILDER DECLARATION
1 hereby affirm that i am exempt from the Contractor's Licenm Law for the
following mason. (Section 70313. Business and Professions Code•. Any city or county
which requires a permit to conssruct, alter. improve, demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit to fk a signed statement
Contractor's License L+w (Chapter9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(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
APN Number
Occupancy Type
Section 7031-5 by any applicant for a permit subjects the applicant to a civil penalty of
am more than five hundred dollars (SS00)
32609041 .200
0 L as owner of the property. or my employees with wages as their role compensation,
Required Inspections
es
will do the work' and the structure is not intended or offered for sak (Sec. 70K Bsirrm
and Professions Code: The ContractorI k=se Law does not apply to an owner of
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property who builds or improves thereon, and who does such wart himself or through bis
own employees, provided that such improvements m not Intended or offered for sale. If.
however, the building or improvement is sold within ane year of completion. the owner -
builder yffilhave the burden of proving that he did not build or improve for purpose of
Las owner of the property, m exclusively contacting with licensed contractors to
construct the project (Sec. 7044. Businm and Professions Code:) The Contractors Lis
cense Law does not apply to an owner of property who builds or impmves thereon. and.
who contracts for such projects with a comae Ws) licensed pursuant to the Comaetars
License Law.
t] 1exempt under See . B & P C for ly mason
OwtrtDate S 14 0q
WORKERS COMPF-NSA71ON DECLARATION
I hereby affirm under penalty of perjury ora of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-Tasure 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.
❑ I have and will maintain Warkcs s Compensation Insurance, as nxpdmd by Section
3700 of the Labor Code, for the performance of the work for which this permit issued
My Workers Compensation Insurance artier and Polley number m:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ane hundred dollars ($ 100)
Of less)
I certify that in the performance of the worlf for wVWkAh this permit is issued. I shall not
employ any person in any manner so c b Worimrs' Compensation
Laws of California.
Applicant
NOTICE TO APPLICANT. if. alter malting this Certificate of Exemption, you should
become subject to the Workers Compensation previsions of the Labor Code, you must
forthwith comply with such provisions or this pormit "I be dcemc-d revoked
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the peifornance of
the wont for which this permit is issued (Sec. 3097, Civ. C.)
Tinders Name
Landers Address
I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state lairs 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
liabilities. judgments. costs and expenses which may in any way seems: against aid City
in consequennc : of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -11 NT
Issued by: Date 5 , Lip Q
SOUR REGUI.ATIO
Re -roofs
Type of Roof
D'
Signature of AppliantlContruxor Elate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hulk hazardous mararial
as defined by to Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cede. Section 25532(a)7All
&141'
roofs shall be inspected prior to any roofing material being installed.
[3y"
If a roof is installed without first obtaining an inspection, I agree to remove
Will tate applicant or future building occupant use equipment or devices which
emit harsrdous air contaminants as defined by tate Bay Area Air Quality Management
all new materials for inspection.
District?
(3 Yes mwa
I haw read the hazardous materials requivernents under Chapter 6.95 of the Cslifrr.
uia Health & Safety Code. Sections 25505.23533 and 25534.1 understand that if the building
dna not currently have a moran4 that It is my tcspo. bility to notify the t of
nequircmcns which must be met r to f a eeniBeale car
Signature of Applicant Date
'"nut'''"`
All roof coverings to be Class '%¢" or better
—��
Owner '
or authori7zd agent Date