09030184CITY OF CUPEKFINU
BUILDING DIVISION PERMIT . . '
BUILDING ADDRESS:
20875 VALLEY
OWNER'S NAME:
_ nONE:
ARCHITEcT/ENGINEER:
app LICENSED CONTRACTOR'S DECLARATION
u 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
y in full force and effect
? License Class Lic• 8
F p Dam Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
DW U
4 toH Licensed Professional
o
0 OWNER -BUILDER DECLARATION
I hereby alrirm that 1 am exempt from the Contractors License law for the
a O following mason. (Section 7031.5, Business and Professions Code: Any city or county
ea Pi which requires a permit to construct alter, improve, demolish, u repair any structure
4"s- prior to its issuance, also requires the applicant for such permit to file a signed statement
cthat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
f— (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y 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
not more than five hundred dollars (5500).
❑ 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
and Professions Code: The Contractors 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 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
d)
I. as owner of the properly, w exclusively contracting with licensed contractus to
construct the project (Sec. 7044. Business and Professions Code:) The Conuactoes 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 Contractors
License Law.
01. eMxefm�pt under Sec. B & P C for this reason
Owner 'r `� Date b b�
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labs Code. for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
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 mannc I as t becogc subject to the Workers' Compensation
Laws of Caltfomta. Date ^ ^
Applicant ,o
It
NOTICE TO APPLI NT: If, after making this Certificate of Exemption, you should
become subject to the Workers 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.)
Lenders Name
Lenders Address
I certify that 1 have read this application and state that the above information is
coffect. 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
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
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RE ULATI NS. C_
Si ure of Applican ontractor — ate
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)? �,,(�
❑Yes u^o
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
District? _ !
❑ Yes n
1 have read 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
docs not currently have a tenant that it is my responsibility to notify the occupant of the
prior req iremcnts whi h must mel or to issuance of a Certificate of rcurcy.
Owner or authorized agent Date
Job Description
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
M/E/P'S-SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Sq. Ft. Floor Area
APN Number
32609064.32
Issued by
Re -roofs
Type of Roof
Valuation
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new rr aterials for inspection.
Signature of Applicant
All roof coverings to be Class':W' or better
Date
PERMIT NO.
T)
n9o3ni 84
PERMrr ISSUE DATE
S A
CONTROL NO.
BUILDING PERMrr INFO
BLDG
ELECT
PLUMB MECH
Job Description
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
M/E/P'S-SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Sq. Ft. Floor Area
APN Number
32609064.32
Issued by
Re -roofs
Type of Roof
Valuation
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new rr aterials for inspection.
Signature of Applicant
All roof coverings to be Class':W' or better
Date