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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20875 VALLEY GREEN DR #2
TBD - TD BE DETERMINED
09030167
PERMIT ISSUE DATE
OWNER'S NAME:
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SXNffAiR CONTROL NO.
nONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) ofDivision 3ofthe Business and Professions Code, and my license is
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
in full fora and effect
License Class
E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK
ontr
Dao Contractor
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ARCHITECT'S DECLARATION
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COMMENTS.
I understand my plans shall be used as public records
i Licensed Professional
OWNER -BUILDER DECLARATION
I
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (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 file a signed statement
that he is licensed to the provisions of the Contractor's License Law (Chapter 9
3q. Ft. Floor Area Valuation
pursuant
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$100
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
APN Number Occupancy Type
not more than five hundred dollars (5500).
32609064 .02
❑ 1, as owner of the property, or my employers with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (See. 7044, Business
iRequired Inspections
and Professions Code: The Conuts actoes License Law donot 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-
buil7 will have the burden of proving that he did not build or improve for purpose of
sec
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's U.
cense Taw 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 ex ppt under Sec. �( B& P C f r th' n
Owner Y y l -' ^ 11 1M�'"��` Date -��
WORKER'S CO PEN ATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ T have and will maintain a Certificate of Consent to self-insum 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.
❑ 1 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 arc:
Came; Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any mannc� tt�cc m to the Workers' Compensation
Laws of California.
Applicant
N0710E TO APPLICANT: if, alter making this Certificate or Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
7_ forthwith comply with such provisions or this permit shall be deemed revoked.
7
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.)
�" Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
" toren. 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.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
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liabilities, judgments, costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit.
-'� APPLICANT UNDERSTANDS AND WIL�WITHALL
Issued by. Date
SO R REGUL TIONS.Re-roofsSignature
o Applicant/Contractor
T of R oof
Type
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(x)?
All shall be inspected prior to any roofing material being installed.
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roofs
❑
a roof is installed without first obtaining an inspection, I agree to remove
ll the applicant or future building occupant use equipment or devices which
Will
emit hazardous air contaminants as dcrrned by the Bay Area Air Quality Manascmcnt all new IT aterials for inspection.
District?
❑ Yet o
1 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 the building
does not currently have a tenant, that it is my responsibility to notify the occupant or dee
Date
requirements which m st be in rt; r uana of a Ccrtificale of O
Signature of Applicant
lV�1V/Il n 14,t e�'1 bi
All roof coverings to be Class' j�`` or better
Owns authorircd agent Da