09030185CITE' OF CUPERTIND
DIVISION PERMIT
BUILDING
BUILDING ADDRESS:
PERMIT NO.
20875 VALLEY GREEND DR # 37
TBD — TO BE DETERMINED
OWNER'S NAME:
K033 92
PERMIT ISSUE DATE
PHONE:
S Art AAIRP?CONTROL NO.
ARCHITECr/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
701] 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
in full force and effect.
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
License Class
Dale Contractor
M/E/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (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 Contractor's (Chapter
(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 violatun 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 rive hundred dollars ($500).
32609064.37
❑ 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 Contractors License Law docs not apply to an owner of
q 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 -
build r will have the burden of proving that he did not build or improve for purpose of
sal . ,
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractoes Li.
cense Law does not apply to an owner of property who builds or improves thereon, and •
who contracts for such projects with a comractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exemptunder Sec, ay B & P C for this reason
Owner Y Y wt-CA6 / V\J� Date -55
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 -insure for Warkers 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 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 for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any mann!Rr la bEcof)lcAhbject to the Workers' Compensation
SS b 1 LJ
Laws of California. ate
Applicant2A I
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.
l
t 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
Lcndees Address
j I certify that I have read this application and state that the above information is
r correct. I agree to comply with all city and county ordinances and slate laws relating to
t building construction, and hereby authorize representatives of this city to enter upon the
ahove-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities,judgments, costs and expenses which may in anyway accrue againslsaidCity
inconsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SC RCE REG LATI NS.
�'
I4 --. 5 d 0
Re -roofs _
Type of Roof
Sign ureofApplicanU ntracmr Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle 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.
❑YesNo
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 contaminantsdefined by the Bay Area Air Quality Management
all new materials for inspection.
District?
0Yes Nu
1 have mad 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 or the
requirements whi4 must be t pn �llyy issuance of a Certificate of Oc
Signature of Applicant Date
YV� _IY`vt�ti ,51161
All roof coverings to be Class''}`' or better
Owner or authorized agent Date