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CITY OF CUPERTINO —7-777777777777
PERMIT
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BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20990 VALLEY GREEN DR #633
TBD - T) BE DETERMINED
PERMIT ISSUE DATE
OWNER'S NAME:
2909
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SA R CONTROL NO.
.. hONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I 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
INSTALL WASHER /DRYER UNITS IN APT S —INCLUDE S
in full form and effect.
License Class Lic."
E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK
Date Contractor
ARCHITECTS DECLARATION
COMMENTS.
1 understand my plans shall be used as public records
i
Licensed Professional
OWNER -BUILDER DECLARATION
I
I hereby affirm that I am exempt from the Contractor's License Law for the
i following reason. (Section 7031.5, 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
9
�q Ft. Floor Area Valuation
r at he is licensed pursuant to the provisions of the ConUactor's License Law (Chapter
t
a(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 of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number Occupancy Type
not more than fire hundred dollars (s500).
32609053.633
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044. Business
Required Inspections
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements arc 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
sa
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense 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.
❑ 1 am exempt under Sec B & P C for thi n
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WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I haat and will maintain a Certificate of Consent to self -insure for Worker's Compen.
sation, as 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 Worker's Compensation insurance, as required by Section
3700 of the labor Code, for the performance of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy number art:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chit section need not be completed if the permit is for one hundred dollars ($100)
or less)
I certify that in the performance ��{{ the w4[it for which this permit is issued. I shall not
employ any person in any manrha3W ash tkcapR 'ect to the Workers' Compensation
Laws of California Dais JJ � V
Applicant 1
NOTICE TO APPLICANT: If, after making this Certificate 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.
CONSTRUCTION LENDING AGENCY
1 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.)
~
aLender's Name
Lender's Address
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1 certify that I have read this application and state that the above information is
-O correct I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction. and hereby authorize representatives of this city to enter upon the
W 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 accrue against said City
Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by. Date 5 • (X, C)
URCE REGULATIONS.
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Re -roofs
Signature of Applicant/Contractor
HAZARDOUS MATERIALS DISCLOSURE
T of Roof
Type
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 shall be inspected prior to any roofing material being installed.
`-
Yes �O
roofs
❑
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air conLaminants7 defined by the Bay Area Air Quality Management all new rr aterials for inspection.
District?
❑ Yes XZ No
1 have real the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
Date
e met prior issuance a'C� ficate oof jup
requir�ort.
Signature of Applicant
�of
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All roof coverings to be Class'A!' or better
Owneare