09030174CITE' OF CUPERI'1NU
BUILDING DIVISION PERINUT
BUILDING ADDRESS:
20875
OWNER'S NAME:
ARCHITECT/ENGMER:
z O O LICENSED CONTRACTOR'S DECLARATION
to I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
:zwU 6 with Section 7000) of Division 3 of tho Business and Professions Code, and my license is
h in full force and effect.
License Class Lie. N
i N O Date Contractor
ARCHITECTS DECLARATION
i I understand my plans shall be used as public records
;WU
'
U. y Licensed Professional
w OWNER -BUILDER DECLARATION
> I hereby affirm that I am exempt from the Contractor's License Law for the
C3 Oa following reason. (Section 7031.5, Business and Professions Code: Any city or county
Ii 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 file a signed statement
S C that he is licensed pursuant to the provisions of the Canractor's License Law (Chapter 9
H (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 rive hundred dollars ($500).
0 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 arc not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
buil r will have the burden of proving that he did not build or improve for purpose of
sa .).
1, as owner of the property, am exclusively contracting with licensed contractors to
can, street the project (Sec. 7144, 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.
0 I am exempt under Sec. B & P C for thi mason
Y f l
Owner ::� V\ -.'^Date —9
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insum Cor WorkePs Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 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:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the ork for which this permit is issued, I shall not
employ any person in any mannerso!5tbcLoon at" c the Workers'Compensadon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workces Compensation provisions of the Labor Code, you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
h 4 CONSTRUCTION LENDING AGENCY
hVl-h I hereby affirm that there is a construction lending agency for the performance of
7 the work for which this permit is issued (Sec. 3097, Civ. C.)
Lt1 A Lenders Name
z Lender's Address
I certify that 1 have mad this application and state that the above infomtadun is
w correct. 1 agree to comply with all city and county ordinances and state laws relating to
r� U building construction, and hereby authorise representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
t We) agree to save, indemnify and keep harmless the City of Cupertino against
t%1 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 NQN-PAINT
Signature of Applicant/Contraclor Uate' z
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes L'V'°
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants at defined by the Bay Area Air Quality Management
District? �,^
O,
Yes ►.7�
I 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 of the
mani—nts which must be meLziriorwisruante of a Certificate of Occupahcy.
authorized
PERMIT NO.
090301 74
PERMIT ISSUE DATE
SANT A CONTROL N0.
BUILDING PERMIT INFO
INSTALL WASHER/DRYER UNITS
IN APTS—INCLUDES Job Description
Sq. Ft. Floor Area
�_'r. o
Required Inspections
Issued by:
Re -roofs
Type of Roof
Type
Date 5 . Lf, 0 9.
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 "{'' or better