09030197BUILDING DIVISION PERMIT
OWNER'S NAME:
ARCHITECT/ENGINEER:
o p LICENSED CONTRACTOR'S DECLARATION
' w C I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
z m with Section 7000) of Division 3 of the Business and Professions Code, and my license is
] y in full force and effect.
t Z License Class Lie. p
H Dale Contractor
ARCHITECTS DECLARATION
o < 1 understand my plans shall be used as public records
)0.0
w y Licensed Professional
I y Ze OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
q o following mason. (Section 7031.5, Business and Professions Code: Any city or county
<� which requires a permit to construct, alter, improve, demolish, or repair any structure
r prior to its issuance, also requires the applicant for such permit to file a signed statement
G that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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 rive hundred dollars ($500).
❑ 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
and Professions Code: The Contractor's License Law docs 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 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
it 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 Seo. \ B & P C f r this ason
Owner �1 ��`^�`�—Dale a
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
Job Description
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
M/E/P'S-SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Sq. Ft.
32609064.113
Area
Required Inspections
Valuation
Occupancy
❑ 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, far the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars ($100)
or less.)
I certify that in the performance of th work for which this permit is issued, I shall not
employ any person in any manner l roc m u j cl to the Workers' Compensation
Laws of California. Dat
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you shmu d
become subject to the Worker's Compensation provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z m"m CONSTRUCTION LENDING AGENCY
(moi 4 I hereby affirm that there is a construction lending agency for the performance of
r7 the work for which this permit is issued (Sec. 3097, Civ. C.)
W A Lender's Name —
Z
Lender's Address
U Q 1 certify that I have mad this application and state that the above information Is
w E~" correcL I agree to comply with all city and county ordinances and state laws relating to
O U building construction, and hereby authorize representatives of this city to enter upon the
> aahovc-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments, costs and expenses which may in any way accrue against said City
rA
U in consequence of the granting of this permit, t
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NrON-POINT Issued by: Date
x/111 A Z E-1 ��dti SJ�_Q q Re -roofs Q _
Signatur o Applicant/Contractor Datc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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
Codc, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ Yes all
Will the applicant or forum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
1-1 Yes o
1 have mad the hazardous materials requirements under Chapter 6.95 of the Cal i for-
nia Health & Safety Code, Sections 25505,25533 and 25534. 1 understand that If the building
does not currently have a tenant, that it is my responsibility to notiry the occupant of the
req s�' mncnnts whic ust bemel prior to uanee ora Ccn;rcato oroccppancy. Signature of Applicant Date
tes ti r, ,�Q i�.l r.� �.> S 16 D . All roof coverings to be Class'n" or better
Owner or authorized agent Date _ _
PKKMI I- NU.
nncin-�ni
q7
PERMIT ISSUE DATE
S A
CONTROL NO.
BUILDING PERMIT INFO
BLDG
ELECT
PLUMB
0
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Job Description
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
M/E/P'S-SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
Sq. Ft.
32609064.113
Area
Required Inspections
Valuation
Occupancy
❑ 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, far the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars ($100)
or less.)
I certify that in the performance of th work for which this permit is issued, I shall not
employ any person in any manner l roc m u j cl to the Workers' Compensation
Laws of California. Dat
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you shmu d
become subject to the Worker's Compensation provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z m"m CONSTRUCTION LENDING AGENCY
(moi 4 I hereby affirm that there is a construction lending agency for the performance of
r7 the work for which this permit is issued (Sec. 3097, Civ. C.)
W A Lender's Name —
Z
Lender's Address
U Q 1 certify that I have mad this application and state that the above information Is
w E~" correcL I agree to comply with all city and county ordinances and state laws relating to
O U building construction, and hereby authorize representatives of this city to enter upon the
> aahovc-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments, costs and expenses which may in any way accrue against said City
rA
U in consequence of the granting of this permit, t
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NrON-POINT Issued by: Date
x/111 A Z E-1 ��dti SJ�_Q q Re -roofs Q _
Signatur o Applicant/Contractor Datc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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
Codc, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ Yes all
Will the applicant or forum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
1-1 Yes o
1 have mad the hazardous materials requirements under Chapter 6.95 of the Cal i for-
nia Health & Safety Code, Sections 25505,25533 and 25534. 1 understand that If the building
does not currently have a tenant, that it is my responsibility to notiry the occupant of the
req s�' mncnnts whic ust bemel prior to uanee ora Ccn;rcato oroccppancy. Signature of Applicant Date
tes ti r, ,�Q i�.l r.� �.> S 16 D . All roof coverings to be Class'n" or better
Owner or authorized agent Date _ _