09030162 CITY OF CUPERTINO
BUILDING DIVISION PERMIT QIZM�ATIf�N,
BUILDING ADDRESS: PERMIT NO.
20990 VALLEY GREEN R #692 TBD - TO BE D
PERMIT ISSUE DATE
OWNER'S NAME:
SXMYA CONTROL NO.
.TONE:
BUILDING PERMIT INFO
ARCHI'IECTIENGINEER:
BLDG ELECT PLUMB M1:CH
v p p LICENSED CONTRACTOR'S DECLARATION Job DCSCflptlOn
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
'oy in full force and effect. INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
Cbz License Class L'c* E/M/P' S-SEE PERMIT #09030198 FOR PLAN CK
F,p Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records COMMENTS.
�yU
4 O y Licensed Professional
OWNER-BUILDER DECLARATION
a ay I hereby affirm that I am exempt from the Contractor's License Law for the
no following reason.(Section 7031.5,Business and Professions Code:Any city or county
a.Pi 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 Valuation
xthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
Y t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $100
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 32609053 . 692
❑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 Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
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-
builder will have the burden of proving that he did not build or improve for purpose of
Zsa
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&P Cg;fo��thhis n
Owner �b /�^'""` Date--��
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 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.
❑I 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 Workers Compensation Insurance carrier and Policy number am:
Carrier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far one hundred dollars($10(0
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 manner so as to becu�crc6subjt tgth�Workcrs'Compensation
Laws of Califomia.Date
Applicant
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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z 0r CONSTRUCTION LENDING AGENCY
I hereby afri m that them is a convection lending agcrcy for the performance of
144> the work for which this permit is issued(Sec.3097.Civ.C.)
W Q Lendefs Name
�0 Lcndees Address
U 0 1 certify that I have read this application and state that the above information is
LL r"' cortccL I agree to comply with all city and county ordinances and state laws relating to
0 V building convection,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
„Ey to liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH L N N-POINT Issued by:
SOURCE REGUL TIONS.
.� 5 b l) Re-roofs
Signature of Applicant/Contractor i5ale T of Roof
MATERIALS DISCLOSURE Type
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)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
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 hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? (/
❑Yes QNo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafetyCode,Sections 25505,25533 and 25534.1 understand"irthe building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
reyuiremcnis which pust be'"�t pngr I issuance of a Certificate ofcup Signature of Applicant Date
�� All roof coverings to be Class'"or better
Owner or authorized agent ��