09030183CITY OF CUPERTINO
PERMITS
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BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20875 VALLEY GREEN DR #28
TBD — TO BE DETERMINED
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OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
S R CONTROL NO.
ARCHITEcr/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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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
in full force and effect.
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
License Class L1
Date Contractor
M/E/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which squires a permit to construct. alter, improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
9
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Cnde) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
100
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).
32609064.28
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
9 P
will do the work, and the struclum is notintended 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 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
Vas 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 Contractors
License Law.
❑ I am exempt underSeca , B & P C or thi saran
�
Owner Y r LI.XI�.X^-� Wr-v ti >—� Date 6 r�
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workees Compen-
satian, 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 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 Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, [ shall not
employ any person in any mann a5 toe ubjecl to the Workers' Compensation
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Laws of California. atc `
n
Applicant -
NOTICE TO APPLICANT: If, after making this Certificate or 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 mvoked.
4 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 -
Lender's Address
I certify that 1 have read this application and state that the above information is
4 cor eL 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
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
SOURCE REGU TIONS
—
1M—tr...� 'I �.�� :5161
Re -roofs _
Type of Roof
Signature of ApplicantlContractor as
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantslore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)?
(('�No
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
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?
Nu
❑Yes
I have sad 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
re uiremenLs whi h must be et rte to issuance of a Certificam or cop
Signature Of Applicant Date
Ty,
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- All roof coverings to be Class "" or better
Owner or authorized agent Date