09030171BUILDING DIVISION PERMIT
BUILDING ADDRESS:
20875
OWNER'S NAME:
PERMIT NO.
PERMIT ISSUE DATE
CONTROL NO.
ARCHITEC (ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
INSTALL WASHER/DRYER UNITS I = Ct I—I II
o p LICENSED CONTRACTOR'S DECLARATION
wE= I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
U w with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class Lic. #
F Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
yU
U. ti Licensed Professional
y OWNER -BUILDER DECLARATION
a I hereby affirm that I am exempt from the Cantractoes License Law for the
00 following mason. (Section 703 1.5, Business and Profcesions 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 file a signed statement
2 G that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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).
❑ 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 Contractors 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. If,
however, the building or improvement is sold within one year of completion, the owner-
builde ill 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 Contractor's
License Law.
❑ I am exempt under Sec B & PSC for this re roan
Owner ^V Y l�/1' �' Date / f/
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 Workees 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 am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nils section need not be completed if the permit is far anc hundred dollars ($100)
or less.)
I certify that in the performance of the work for ich thi permit is issued, I shall not
employ any person in any mannerso as tolsm Wecl ({Ijkcrs'Compcnsation
Laws Of California. Dalc ff33 n
Applicant � k%, +
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.
~ CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
Y > the work for which this permit is issued (Sec. 3097, Civ. C.)
ALendces Name
,z Lenders Address
J Q 1 certify that I have read this application and stale that the above information is
y correct. 1 agree to comply with all city and county ordinances and slate laws relating to
U 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
b raj] liabilities, judgments, costs and expenses which may in any way accrue against said City
J Z in consequence of the granting of this permit.
t --t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL 1/ON-PAINT
Signature of Applicant/Contractor Dau:'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes (F]jIb
Will the applicant or future building occupant use equipment or devices which
emir hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes t x61
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if tho building
does not currently have a tenant, that it is my responsibility to notify the Occupant Of the
regUU're ccpis which ust be meU�prior to issuance of a Certificate of Occup y.
Owner or authorized agent Date
IN APTS-INCLUDES Job Description
Ft.
APN Number
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Date 5,. (.P . 09
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