09030168CITY OF CUPEKTINU
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
20875
OWNER'S NAME:
PHONE:
ARCHITECT/ENGINEER:
p zo LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
U t with Section 7000) of Division 3 of the Business and Professions Code, and my license is
o y in full force and effect.
X License Class Lic. ff
F- G Dam Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
U
V. I- Licensed Professional
low OWNER -BUILDER DECLARATION
a I hereby affirm that I am exempt from the Contractor's License Law for the
Ca o following reason. (Section 7031.5, Business and Professions Code: Any city or county
m 9 which requires a permit to construct, alter, improve, demolish, or repair any structure
z y prior to its issuance, also requires the applicant for such permit to file a signed statement
G 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
r3 . 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 penally of
not more than rive 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 Conuactoes License Law dons 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-
buildeyCviB have the burden of proving that he did riot build or improve for purpose of
IFa; owner of the property, am exclusively contracting with licensed contractors to
ns uct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cedse Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a conLmctor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sea. B & P C for this reason
Owner �' " ` i/� vv'w e' Date g
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 ror Workers compen-
sation, as provided far 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 Workers 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 for one hundred dollars ($100)
or less.)
I certify that in the performance of thwork fohwhich this permit is issued, I shall not
employ any person in any mannc=3 b6omk suryl he Workers' Compensadon
Laws of California Dater 1 r
Applicant V�
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions or the Labor Code, you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
r—' CONSTRUCTION LENDING AGENCY
-r H I hereby affirm that there is a conswctinn lending agency for the performance of
x > the work for which [his permit is issued (Sec. 3097, Civ. C.)
=1 A Lendces Name —
? 7 Lender's Address
J 0 1 certify that I have read this application and state that the above information is
H correct. I agree to comply with all city and county ordinances and state laws relating to
3 U building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
rAliabilities, judgments, costs and expenses which may in any way accrue against said City
J in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL
ALL 4ON-PODIN
T
SOURCEREGLAI
-�tpµS�1
Signature ofApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mumct 1 Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants az defined by the Bay Area Air Quality Management
District?
E] Yes
No
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 thatif the building
does not currently have a tenant, that It is my responsibility to notify the occupant Of the
requirements which mug be met prjar to su cc or a Certificate of Occupancy_
Owner or authorized agent Date
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.(DOUBLE FEES)
Sq. Ft. Floor Area
32609064.05
Required Inspections
Issued by:
Re -roofs
Type of Roof
Occupancy Type
Date C5, (-Q,
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
PERMIT NO.
PERMIT ISSUE DATE
S A
CONTROL No
BUILDING PERMIT INFO
BLDG
ELECT
PLUMB
0
0
a
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.(DOUBLE FEES)
Sq. Ft. Floor Area
32609064.05
Required Inspections
Issued by:
Re -roofs
Type of Roof
Occupancy Type
Date C5, (-Q,
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