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CITE' OF CUPERTINO
+fi1�i'�]L IUTIaIY.
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20990 VALLEY GREEN DR #600
TBD — TO BE DETERMINED
09030085
OWNER'S NAME:
PERMIT ISSUE DATE
WA §161
PHONE:
S I fft CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
HLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job DOSCrIpt10R
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division3oflheBusinessandProfessionsCode.andmylicenseis
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
in full force and effect
License Class
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
Conte
Dam Contractor
Date
ARCHITECI'SDECLARATION
1 understand my plans shall be used as public records
COMMENTS.
,
Licensed Professional
OWNER -BUILDER DECLARATION
I
I hereby affirm that I am exempt from the Contractor's License Law for the
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
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant Car such permit to file a signed statement
Law 9
that he is licensed pursuant to the provisions of the Contractor's License (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) ser
$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
net more than five hundred dollars ($500).
32609053 .601
❑ I, as owner of the property, or my employees with wages az their sole compensation,
Required Inspections
9 P
will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does suchwork himself or through his
own employees, provided that such improvements are not intended proffered 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
sal
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 contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Seo. B & P C for thls azon
Owner to
WORKER'S COMP SATION DECLARATION
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 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.
1711 have and will maintain Worker's Compensation Insurance, az required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workets Compensation Insurance carrier and Policy number am:
Cartier.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 wor for w ich this permit is issued, I shall not
employ any person in any manner so as co e s bj a Workcrs' Compcnsaton
Laws of California.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you shoul
become subject to the workers Compensation provisions of the Labor Code, you must
7 forthwith comply with such provisions or this permit shall be deemed revoked.
11 CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
> the work for which this permit is issued (Sec. 3097, Civ. C.)
~ Lendets Name
'
Lender's Address
1 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 laws 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
nliabilities,
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- O1NT
Issued by: Date 5,co 0
SOURCE REGULATIONS.
Re -roofs _
Type of Roof
yp
Signature of Applicant/Contractor I Datdi
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
az 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.
❑Yes 4/6
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?
11 Yes o
I have mad the ha7mdous materials requirements under Chapter 6,95 of the Cali for-
nia Health & Safety Code, Secdons 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
requirements which mut be mel p or to h uance of a Certificate of Occ an
Signature of Applicant Date
' M /a`,�2 i��1�Ltl A / D�
All roof coverings to be Class''}`` or better
Owner or authorized agent IDate