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CITY OF CUPERTINO
DIVISION PERlYIIT�kGTt?�•
BUILDING
BUILDING ADDRESS:
PERMIT NO.
20875 VALLEY GREEN DR #11
TBD - TO BE DETERMINED
OWNER'S NAME:
XCAR Q-2
PERMrr ISSUE DATE
PHONE:
SAN CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
INSTALL WASHER/DRYER UNITS
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
IN APTS-INCLUDES 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
License Class Lic. M
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
License Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's (Chapter
(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
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).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure Is not intended 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 thmugh 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
sale •
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 Contractors
License Law.
❑ I am exempt under Sega B & P C or th• reason
1
Owner ' , `A2 �l.-"+ i� Date 1)
WORKER'S COMPENSATION 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 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 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 k for w ich this permit is issued, l shall not
employ any person in any mannersoV c es bjcctlm Workers'Compensation
Laws of California. Dots IIJJ
Applicant
NOTICE TO APPUCA : If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions or the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
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.)
Lenders Name --
Lendees Address
I certify that I have read this application and state that the above information is
correct 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.
(Wc) agree to save, indemnify and keep harmless the City or Cupertino against
j liabiliiles, judgments, costs and expenses which may in any way accrue against said City
iin consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N -P NT
Issued by: Date 5 • (,V, V l
S U C REGULATIONS.
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Re -roofs
Type of Roof
„b.c.-�
Signature of Applicant/Contractor 152to
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muni' I Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed,
❑Yes o
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 contaminans as cfined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Yes Nu
1 have mad the hazardous materials mquimments under chap cr6.95 arthe Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occuP t or the
requi``�``�'' s which m t be met pn t ee of a Certificate of c7 aney
Signature of Applicant Date
�r ��`A`t ��'1'"`- d
All roof coverings to be Class r'}Q" or better
—1-1-L
Owner or authorized agent ate