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CITY OF CUPERTINO
DIVISION PEI2IYIIT�+
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BUILDING
BUILDING ADDRESS: _
PERMIT NO.
20975 VALLEY GREEN DR #308
TBD - TO BE DE
OWNER'S NAME:
PERMITISSUEDATE
PHONE:
SXMYA CONTROL NO,
ARCHITECl/BNGINEER:
BUILDING PERMIT INFO
BLDG ELO PLUMB ME�CH,
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
License
DaContractor Date Cactor
Da
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITECPS DECLARATION
I understand my plans shall he used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, 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 file a signed statement
License Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractors (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
$100
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
32609041 .308A
❑ 1, as owner of the property, or my employees 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 Code: The Contractor's License Law does not apply to an owner of
9 P
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
Vsale.
as owner of the property, am exclusively contracting with licensed contractors to
co91ruct the project (Sec. 7044, Business and Professions Code:) Ile Contractors Li-
ccnse Law does not apply to an owner of property who builds or improves thereon, and •
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & PQC for this ¢1 asoon
Owner 1 aAIN-4-A V\ � Date
WORKER'S COMPENSATION DECLARATION 1
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure 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 Workces Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier.Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the wort for w tch this permit is issued, I shall not
employ any person in any manner so ebfc fire b' the Workers' Compensation
Laws of Califomia. Dal
Applicant
NOTICE TO APPLICA9T. If, after making thisertifrcate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
1
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ, C.)
Lender's Name
Lender's Address
j I certify that I have read this application and slate that the above information is
correct I agree to comply with all city and county ordinances and state laws relating to
' building construction, and hereby authorim representatives of this city to anter upon the
for inspection
above-mentioned property purposes.
(We) agree to save, indemnify and keep harmless the City of Cuperino against
! liabilities, judgments, costs and expenses which may in any way accrue againstsaidCity
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON- DINT
Issued by: Date 5 rO
SOURCEREGUATIONS.
Q 6
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s P A.4 V�.��.v..,
Re -roofs
Type of Roof
Signature of Applicant/Conuaclor Da
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
E] Yes Lyrvo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or [alum building occupant use equipment or devices which
emir hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
OYrs
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand Ihatif the building
does not currently hast a tenant, that it is my responsibility to notify the occupant f the
requirements which must be mel ndr to issuance of a Certificate of Occup ey
Q11 .4 ' .., ,a . d�
Signature of Applicant Date
All roof coverings to be Class %` or better
Owncr or authorised agent Dat