09030165BUILDING DIVISION PERAUT
BUILDING ADDR
20990
OWNER'S NAME.
ARCHnEcT/ENG1NEER:
p C LICENSED CONTRACTORS DECLARATION
i U 1 fib' alarm that I me Bxtmcd under provisions of Chapter 9 (commencing
with Section 700) of Division 3 of die Business and Profaasions Code, and my license is
n in full fora and effect.
MLicense Class LAC.
qq
Dots Contractor
I F ARCHITECTS DECLARATION
e I understand my pians shall be used as public records
by
s tI iccnwd Profosalonal
OWNER -BUILDER DECLARATION
I hereby arm that 1 me exempt from the Contractor's license Law for the
,ca following won. (Section 70315, Business and Professions Code: Any city or county
J$ g which mquhw a permit to cmuwwt, alter. improve, demolLsh, or repair any suucturc
y prior to its issuance. also requires the applicant for such permit to rick a signed sutrmcni
a dw he is licensed pursuant to the provision of the Contractor's License Law (Chapter 9
$ (commencing with Section 7000) of Division 3 -of the Business and Profession Code) or
6 .. eat be is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a evil penny of
not more tem live hundred dollars (5500).
❑ L as owner of the property, or my employ= with wages as their sole compensation,
will do the wort, and the structure is not intended or offered for sale (Sec. 7044. Business
and Profession Code: The Contractor's License Law does mot apply to aro owner of
property who builds or improves thereon. and who does such wort himself or through his
we enployces, provided Out such improvements are not intended or offered for sale. ff.
however, the building or improvement is sold within one year of completion. the owner-
builder
wnerbuilder will lava the burden of proving that he did not build or improve for purpose of
to
L as rwner of the property, ere exclusively contracting with licensed contractors to
consrnn:1 the project (Sec. 7044. Business;and Profession Code:) The cooactoes l-
ame Law does not apply to an owner of property who builds or improves duereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
Lice= Law.
❑ 1 am aetmpt underpSee B& P C orthis
Owner 1 ► I Jl�til n.. �i/�AM-- Date e
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury aro of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -Insure forWorirer's Compcn-
sadon as Provided for by Section 3700 of the labor Code, for the performance of to
wort for which this permit is issued
❑ 1 have and will maintain Worker's Compensation Insure, as required by Section
3700 of the labor Code, for the performance of the wort for which this permit is issued
My Worker's compensation insurer crier and Policy number am:
Curler Policy Na:
CF.XMCATE OP EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not ba complecd If the permit is forep hundred dollars ($100)
or less.)
I certify that in the performance ofthe grk ww" this it 4 famed. I ensu not
employ any pawn ire any manner�c b' Worixera' Compensation
Lawn of California Date
Applicant ti/1 n
NOTICE TO APPLICANT: If, after mating this Certificate of Exemption, you should
become subject to the Worker's Compensation provision of the Labor Code. you mug
Q forthwith comply with such provision o
or this pumnit shall be domed revoked.
CONSTRUCTION LENDING AGENCY
(~—r W) 1 hereby aflimn the there is a con ruedon lending agency for the performance of
14 > the wort for which this permit is isfued (Sec 3097, Civ. C)
QLender's Name
= Z Lender's Address
a I certify that I have read this appllcatien and stale aha the above infamaimn is
t" correct. I agree to comply with all city and county ordinances and sate laws relating to
0 p 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 kap harmless the City of Cupertino agalrm
,raj)' liabilities, judgments, costs and expenses which may in any way accrue against said Clty
V 7 in consequence of the granting of this permit.
rte- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGU ONS.
Signature of Applicant/Contractor —
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocoepanl store or hurdle hmrdoos material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Sealom 25532(x)?
❑ Ya
Will the applicant or future building occupant use equipment or devices which
emit huArdoum sir contaminants d as defined by the Bay Area Air Quality Management
DLwier
❑ ,
Yrs �Nm
I have rad the hazardous materials requirements under Chapter 695 of the Califor-
nia Health & SafetyCode. Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a taunt, my responsibility to notify the oxupaut of the
nu w ' mem be t r to issuance of a Ccrifiatc of
Owner or authorized agent &C
PERM11 Nu.
PERMIT ISSUE DATE
CONTROL NO,
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 0 a
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Ft. Floor Area
32609053.707
Required Inspections
Issued by:
Re -roofs
Type of Roof
Tyle
Date C , Lp - 0
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