09030153CITY OF CUPERTINO
PERMIT
`'�RTI�1Y.
BUILDING DIVISION
::-
BUILDING ADDRESS:
PERMIT NO.
20990 VALLEY GREEN DR #630
TBD - TO BE DETERMINED
0903015-3
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
S R CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMrrINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job DOSCTIptIOR
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
in full force and effect.
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
Conti
Date Contractor
Date Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter^ improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant Cor such permit to file a signed statement
License Law 9
that he is licensed pursuant to the provisions of the Contractor's (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1 O 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
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 ($500).
32609053 .630
❑ I, as owner of the property, or my employees with wages as their sole compensation,
ns Required Inspections
fl p
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 docs 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 are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner-
build will have the burden of proving that he did not build or improve for purpose of
sale .
I, as owner of the property, am exclusively contracting with licensed contractors to
cons uct 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.
❑ I am QQ\xeJm�p/t�under Sego. ` , B & P C fm thls rc on
Owner Jr r ` A—�i �l v`�—`--9a1e 0
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insum for Workees 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 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 Workces Compensation Insurance carrier and Policy number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit Is forone hundred dollars ($100)
or less.)
I certify that In the performance of the wk for hick this permit Is issued, I shall not
'
employ anypersoninany mannersogstmbc�ome ubjegi Workers'Compensadon
Laws of California. Dale 7 ��
Applicant
NOTICE TO APPLICANT: If, after making this i rcato of Fatcmption, 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
I hereby affirm that there is a construction lending agency for the performance of
1 the work for which this permit is issued (Sec. 3097, Civ. C.)
Lendoes Name
Lender's Address
I certify that I have read this application and state 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 authorize representatives of this city to enter upon the
for inspection
above-mentioned property purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments. costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOU CE REGU ATION
—
Re-roofs _
Type of Roof
Signature of Applicant/Conlractor data
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 Safely
Code, Section 25532(a)7All
roofs shall be inspected prior to any roofing material being installed.
yN
❑Yes [o
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 contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? — /
C] Yes Cita
1 have read the hazardous materials requirements under Chapter 6.95 or 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 noUry the occup t or the
req t cots whi must be `�t poor tr m uancc of a Ccnifmcatc of Oce pagcy
Signature of Applicant Date
na x
All roof coverings to be Class''" or better
'
Owner or authorized agent i7atc