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CITE' OF CUPERTINO
PERMIT
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BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20875 VALLEY GREEN DR #61
TBD - TO BE DETERMINED
OWNER'S NAME:
Tmnn; F'(ITTI\TTIATTON
PERMIT ISSUE DATE
eHONE:
SXMYAift9.CONTROL NO.
ARCHITECT/ENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
in full fore and effect.
License Le•x
Contractor
E/M/P' -C—SEE PERMIT #09030198 FOR PLAN CK
D
Date
ARCHITECT'S DECLARATION
COMMENT S
I understand my plans shall be used as public records
.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
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
Sq. Ft. Floor Area
Valuation
! prior to its issuance, also requires the applicant for such permit to file a signed statement
i that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$100
: 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
APN Number
Occupancy Type
not mora than five hundred dollars (M).
3 2 6 0 9 0 E 4. 61
❑ I, as Owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q P
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Conuactoes License Law dors 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
sale,Y
I, as owner of the property, am exclusively contracting with licensed contractors to
constrict 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 themon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec. B & P C for thi rcasmn
')wner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compcn-
sation, as provided for by Section 3700 of the Lahr 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 Workees Compensation Insurance carrier and Policy number am.-
m:Came
CarrierPolity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit )s issued, 1 shall not
employ any person in any manncisp to tcgplt:.�ubject to the Workers' Compensation
Laws of California. Date` S 1 P7 -
^ A��`
Applicant c6&44 - `'
NOTICE TO APPLICANt. if, after making this crtificate 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
I hereby &[firm that there is a construction lending agency for the performance of
~ the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender'sName
Lender's Address
7
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
~ 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
nliabilities, judgments, costs and expenses which may in any way accrue against said City
7 in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
TfONSS =
VV✓,,,A 5 (6 1 A
Issued by. Date
Re -roofs
Signature of Applicant/Contractor D fe
HAZARDOUS MATERIALS DISCLOSURE
Type of F.00f
Will Ute 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)?!/
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes C240
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 n laterials for inspection.
District?
❑Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Codc, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a ten that it is my responsibility a notify the occupant Of the
reyu' mens whit must be pri issuance of a Certificate of Occur err.
Signature of Applicant Date
d
All roof coverings to be Class". `' or better
Owner or authorizcd agent D2td