09030163BUILDING DIVISION PERMIT
BUILDING ADDRESS: — — PFRMrr NO.
20990 VALLEY GREEN DR #693 TBD - TO BE D TERMTNED nan3n1h-
OWNER'S NAME: PERMrr WUP DATE
ARCHrrEC rfENGfNEER:
i p p LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commenting
< wbb Sectiw 7000) of Division 3 of rho Business and Pmfesdona Cade, and my license is
H in full forts and effect
t z Lkansc Clan Lie. s
F- qqq DateContractor
l ARCHrIF.CI'S DECLARATION
I understand my plans shall be used as public records
)yU
In Licensed Professional
) 0 :1 OWNER -BUILDER DECLARATION
< 1 hereby affirm that I am exempt from the Contractor's License law for the
.00 following mason. (Salon 70313, Business and Professions Coda Any city or county
$ V which requires a permit to cortnrtcL alter, hnprowe, demolish, or repair any structure
z `~ prior to its Luugncc also requires the applicant for such permit to file a signed natcmrnt
r G that he is licensed pursuant to the provisions of the Contractor's Licemc law (Chapter 9
2
(commencing with Section 7000) of Division 3 of the Business and Profesdons Code) or
o `< 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
not more than five hundred dollars (S300).
❑ 1. as owner of the property. or my employees with wages as their sole compensation,
will do the work and the structure is rot Intended or offered for sale (Sec 7014, Business
and Professions Code: The Contractors License Law don not apply o an owner of
property who builds or improves thmem and who does such wort himself or through his
owe 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 -
bud"
wnerbull have Use burden of proving that he did not build or Improve for propose of
tale
L u owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions code:) The combauoes u-
ccon Law does nes 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 Contractors
[Jerrie Law.
❑ lam ^exeempptt under Sec ��a ` B & P C for this q
Owner V Y , � l� ✓ l/�M7afe 11
WORKERS C S N DECLARATION
I hereby affirm under penalty of puxjury tone of the following declarations
❑ 1 have and will maintain a Cardficato of Co sem toself-insure for Workers Compen-
sadon, 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 win maintain Workers Comprmu lon Innsunrrm, as mgdred by Section
3700 of the Labor Code, for the performance of the work for which this permit L issued.
My Workers Compensation Insurance carrier and Policy number are:
❑artier. Policy No.:
CERMCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need rot be completed i tbc permit is for one hundred dollars ($100)
or leas.)
I error gut in the performance of the w�prk for w this permit Is issued. I shall net
employ any person in any mauncr-„P1bccbe ject6tMt�yorirers' Compensation
Laws of California. Due l I1 vv
Applicant —
NOTICE TO APPLICANT: If. after making this Certificate of Exemption. you should
become subject to the Workcrs Compensation provisions of the Labor Code, you must
❑ O forthwith comply with such provisions or this permit shalt be deemed revolmd
CONsmucnON LENDING AGENCY
rA- 1 hereby affirm that thele is a construction lending agency for the performance of
a. > the work for which this permit Is issued (Sec. 3097, Civ. C.)
aQ Lenders Name
,z, Lenders Address
U 0 1 certify that I have read this application and sulm dud the above information is
V. r"r correct. I agree to comply with all city and county ordinances and state laws mating to
0 V building construction, and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
Gy (We) agree to save, indemnify and keep harmless tin City of Cupertino against
Cn liabilities, judgments, costs and expanses which may in any way accrue against said City
U 7 in consequence of the granting of this permit.
r� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- INT
S URCE IIFAU TIONS.
' V” L " „r.
signua. oTAppl
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Occupant oup9= or handle bmrdom material
as defined by the Cupertino M pal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(x)7
01
Wits the applicant or future building occupant use equipment or devises which
emit har rdous air conumlrV de0rcd by the Bay Area Air Quality Managcmcnt
Dlnrxt7
❑ Yes No
1 have read the hazardous materials mquhemcnts under Chapter 693 of tine Califor-
ma Health dr Safety Code, Sections 25505.25533 and 25534. l understand that if Ihm building
don net turm ay have a tenant. slut it is my responsibility o notify the occupant of gar
require nu which reed prior LsYIiLE of a�Cenifican of O ��
Owner or authorized agent 1V��V�./w� Date
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
Job Description
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
E/M/P'S-SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Sq. Ft. Floor Area
APN Number
32609053.693
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
TYPe
Date 5 . co ,(D
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 "n' or better