09030181BUILDING DIVISION PERMIT
)ING ADDRESS:
OWNER'S NAME:
ARCHITECffENGINEER:
o p LICENSED CONTRACTOR'S DECLARATION
i U I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
7a. m with Scction 7000) of Division 3 of the Business and Professions Codc, and my license is
! :a y in full force and effect.
h Z License Class Lic. #
F DateContractor
ARCHrMCTS DECLARATION
I understand my plans shall be used as public records
)yU
w w Licensed Professional
t y a OWNER -BUILDER DECLARATION
j a I hereby affirm that I am exempt from the Contractor's License Law for the
. o o 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
Z } prior to its issuance, also requires the applicant for such permit to rile a signed statement
x < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
i In
(commencing with Section 701X1) of Division 3 of the Business and Professions Code) or
15F 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).
❑ I, 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 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 -11,
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
sale.).
WI, 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 contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sea B & P C�for
�this reason
Owner �° V 1 1 r ; I!'iL� IG, Date 51 fJ_I _D I
WORKER'S COMPENSATION DECLARATION 'I
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 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.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work forwhich this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the permit is foronc hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, l shall not
employ any person in any manncgso bp c c subject to the Workers' Compensation
Laws of California. Dare - 5. / � rO a v
Applicant 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
h"r CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
Yi > the work for which this permit is issued (Sec. 3097, Civ. C.)
1.1 Q Lendce Name
`z Lender's Address
J Q I certify that 1 have read this application and state that the above information is
Ja correct. I agree to comply with all city and county ordinances and state laws relating to
C.i building construction, and hereby authari7e representatives of this city to enter upon the
a above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
� fA liabilities, judgments, costs and expenses which may in any way accrue against said City
J z in consequence of the granting of this permit.
h - APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL -POINT
S CE REG CATION
per. .51Z �(
Signature of Applicant/Contractor —rDate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hayardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes tla nn
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?
❑ YesNo
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHealth&SafetyCode,Sections 25505,25533 and 25534. 1 understand that ifthe building
does not currently have a tenant, that it is my responsibility to notify the occupant or the
re vire n, is whir must el�ri9r to issue uan c of a Certificate 6 pglt61
Owner or authorized agent Date%�W�I��.J (O�Date
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
M/E/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Ft.
on
APN Number Occupancy Type
32609064.24
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date n, (0.0
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 materials for inspection.
Signature of Applicant Date
All roof coverings to be Class',n" or better
PERMIT NO.
ncmini Ai
PERMIT ISSUE DATE
S R
8 9
CONTROL NO.
BUILDING PERMIT INFO
BLDG
ELECT
PLUMB
0
0
0
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
M/E/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Ft.
on
APN Number Occupancy Type
32609064.24
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date n, (0.0
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 materials for inspection.
Signature of Applicant Date
All roof coverings to be Class',n" or better