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CITY OF CUPERTINO
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BUILDING DIVISION PERIVIIT
BUILDING ADDRESS:
PERMIT NO.
20990 VALLEY GREEN DR #702
TBD - TO BE DETERMINED
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OWNER'S NAME
PERMIT ISSUE DATE
PHONE;
S CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
nf�Sx���aDivision 3ofthe Bush= and PrafcaaiauCode aodmylicencis t.
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
Date Cnse can - ontractor
E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK
ARCHITECTS DECLARATION
I understand my plana shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 70313, 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 aalemem
Conuactoes License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licenced pursuant to the provisions of the
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
$100
that be is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Season 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
not more dm five hundred dollars ($-'=).
32609053 .702
❑ 1. as owner of the property, or my employees with wages as their sole compensation,
e lls
Required Inspections
9 P
will do the work, and the structure is not intended oroffered for sale (See.7044,Business
and Professions Code The Contractor's License Law does not apply to an owner or
property who builds or improves theaeon, and who does such work himself or thmugh his
own employees, provided dist such improvements are not intended or offered for axle. If,
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however, the building or impmvement is sold within one year of completion, the owner-
bu will have the hruden of proving that he did not build or improve for purpose of
L as owner of the property. am exclusively contracting with licensed amusaors m
construct the project (Sec 7044. Business and Professions Code:) Tim Cootracu is Ll -
anis Law does not apply to in owner of property who builds or improves thereon. and.
who contracts for such projects with a conuactor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. , B k P C for this mason
Owner aiS�Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self-humm for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of Ihn
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 isared
'
My Worker's Compensation Insurance carrier and Policy number ace:
Cartier. Policy No.:
CERTIFICATE OE EXEMPTION FROM WORKERS'
COMPENSA71ON INSURANCE
(This section need not be completed if the permit is forone hundred dolWs ($100)
or less.)
I certify that in the perfonnaoce of the wory for wfich this permit is issued. I shall not
employ any person in any manner m Workaa' Cwnpensarlon
Laws of California t C
Applicant
NOTICE TO APPLICANT. If. after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
1
CONSTRUCTION LENDING AGENCY
I hereby affirm this there Is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097. Civ. C)
Lenders Name
Larders Address
I certify that I have read this application and sato that the above information is
' corrccL I agree to comply with all city and county ordinances and state laws misting to
ibuilding construction. and hereby lahorim representatives of this city to rntcr upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and kap harmless the City of Cupertino against
l liabilities, judgments, costs and expenses which may in any way imam against said City
9�01_
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH A NON -POINT
Issued by: Date / ^
SCIVRCE REGULATIONS.
Re -roofs
'•- ✓ ,-,-, S 6 1 04
Signaua olAppiicam/Contracui Dkc
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building onxmpanL store or handle heardons material
as defined by the Cupertino Muni ' d Code. Chapter 9.12, athe Health and Safety
Code. Section 23332(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Ya 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 haxardoua air contaminants as defined by the Bay Ates Air Quality Management
all new materials for inspection.
Disuic7
❑ Yes vo
1 have read the hvardous matedib requirements under Chapter 6.95 of due Califor-
nia Health R SafeiyCmdc, Sections 25505.25333 and 25334. I understand the if tie building
darts not currently have a tenant. that it is my responsibility to notify the occupant of the
mqu
n%}which mat be mm o ofa Certificate of
Signature of Applicant Date
j Cr
A '' n•�'t AA_,A ' ' atter D t
All roof coverings to be Class 'A" or better
Owner or authorlxed agent