09030182CITE' OF CUPEKfINU
BUILDING DIVISION PERMIT
BUILDING ADDR
2087E
OWNER'S NAME:
ARCHITECT[ENGINEER:
94 Z LICENSED CONTRACTOR'S DECLARATION
cwi I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
m with Section 7000) of Division 3 of the Business and Professions Code, and my license is
a y in full force and effect.
Z License Class Lic. N
t~ Date Contractor
�y ARCHITECTS DECLARATION
ryw 1 understand my plans shall be used as public records
yU
0 Cn Licensed Professional
y < OWNER -BUILDER DECLARATION
a I hereby affirm that I am exempt from the Contractor's License Law for the
a c following reason. (Section 7031.5, Business and Professions Code: Any city or county
m which requires a permit to construct, alter, improve, demolish, or repair any swcture
r prior to its issuance, also requires the applicant for such permit to file a signed statement
O that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
i $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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 ($500).
❑ 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 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 bu'tding or improvement is sold within one year of completion, the owner -
builder wi ave the burden of proving that he did not build or improve for purpose of
sale J.
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 contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sean _ / , B & P C f r thi reason
Owner ) 1 / A/P I_. N fes= Date
WORKER'S COMPENSA71ON 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 forworkees 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 are:
Cartier. 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 wrk for hich this permit is issued, I shall not
employ any person in any manner soto-to�ego� a uh('cl}rrtheWorkers'Compensation
Laws of California. Da JJ ll CC..JJ''ll
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
O forthwith comply with such provisions or this permit shall be deemed revoked.
0--4 CONSTRUCTION LENDING AGENCY
co
I hereby affirm that there is a construction lending agency for the performance of
14 > the work fur which this permit is issued (Sec. 3097, Civ. C.)
4 QLenders Name
Lenders Address
;) 0 f certify that 1 have read this application and state that the above information is
y+ Hcorrect. I agree to comply with all city and county ordinances and state laws relating to
C.% building construction, and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
rA liabilities, judgments. costs and expenses which may in anyway accrue against said City
7 in consequence of the granting of this permit.
rte- APPLICANT UNDERSTANDS AND WILL COMPLY WITH A Mq
INT
SO R E EGUL ONS.
`
Signature of Applicanl/Contracloc bliter
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Manicip Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes o
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as'fried by the Bay Area Air Quality Management
District?
❑Yes No
I have read the hazardous materials requirements under Chapter 6,95 of the Califor-
niaHealth & Safety Cade, Sections 25505,25533 and 25534. 1 understand that ifthe building
does not currently haw a tenant. that it is my responsibility to notify the occupant of the
req me is which must be l prior to issuance of a Certificate ofupon
sl6 D 9
Owner or authorized agent Dale
PEKMII NU.
CONTROL NO.
BUILDING PERMITINFO
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,
Area
Valuation
APN Number Occupancy Type
32609064.26
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date 5 •(D, 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 "A" or better