09030158C
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CITY OF CUPERTINO
DIVISION PERMIT
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BUILDING
BUILDING ADDRESS:
PERMIT NO.
20990 VALLEY GREEN DR #662
TBD — TO BE DETERMINED
OW NER's NAME:
PERMIT ISSUE DATE
PHONE:
S A CONTROL NO,
ARCHITECrfENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) ofDivision 3 of the Business and Professions Cade, and my license is
in full force and effect.
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
License ClassLie. t/
Date Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCH 17ECPSDECLARATION
1 understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 or the Business and Professions Code) or
$100
that he is exempt therefrom and Ore basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
32609053.662
❑ i, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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will do the work. and the structure Is not intended or offered For sale (Sec. 7044, Business
and Professions Code: The ContractorLicense Law does not 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 aroRered forsale. 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
sal
1, az owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7144, Business and Professions Code:) The Contractor's Li-
cense Caw does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a cone actor(s) licensed pursuant to the Contractor's
License Law.
1-11 am axxe-mpt_ under Sec. B & P C for this reason
,1t
Owner V�/�""'�`''� �-'�—vim--.-.Pale 53 In
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ ]have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the parformance 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 are:
Cartier,Policy No.:
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed irthe permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the work for w •ch this permit is issued, I shall not
employ any person in any manner soaz� baco9 s bjecl to the workers' Compensation
Laws of California. D tie �t7 V
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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
+ 1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the above information is
4 correct. I agree to comply with all city and county ordinances and state laws relating to
4 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
I liabilities, judgments, costs and expenses which may in any way accrue against said City
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in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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Issued by: Date l
SO RCE REGULATIONS.
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Re -roofs
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Signature of Applicant/Contraclor ate
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle havardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
[y'No
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
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 az defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505, 25533 and 25534., understand Ibat if the building
does not currently have a tenant, that it is my responsibility to notiry the Occupant of the
requirements which must be mel prior t==!qDatc�
Signature of Applicant Date
9 AAjl�
. All roof coverings to be Class "n" or better
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Owner or authorized agent