09030193CITY OF CUPERTINO
� T":
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20875 VALLEY GREEN DR #74
TBD — TO BE DETERMINED
090-40193
OW NER's NAME:
PERMIT ISSUE DATE
PHONE:
S R CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job DOSCTIptlOn
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 force and effect.
License Class o
Contractor Date o
M/E/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (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
that he is licensed pursuant to the provisions of the Contractors License Law (Chaptcr9
(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
31.5 by any applicant for a permit subjects the applicant to a civil penalty of
SeWd.tffih.
APN Number
Occupancy Type
nehan rive hundred dollars (s50o).
32609064.74
ner ofthe property, or my employees with wages as their sole compensation,
ns Required Inspections
q p
work, and thestructureIsnotintendedorafferedforsale(Sec.7044,Business
and Professions Code: The Contractors License 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 or offered forsalm 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.)
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 contractors) licensed pursuant to the Contractors
License Law.
❑ I am exempt under See B & P C for thi mason
B..._5De
Owner'\ �%`^
KER'SCOMPDECLARATION
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 Workees 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 Workers Compensation Insurance, as mquimd 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:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
!4 orpp�tlbject to the Workers' Compensation
employ any person in any mannJ
Laws of California. D�Ic (IMM
Applicant r ^r
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compcnsdtion provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
y 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 (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
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.
4 (We) agree to save, indemnify and keep harmless the City of Cupertino against
City
F1 liabilities, judgments, costs and expenses which may in any way accrue against said
in consequence of the granting of this permit.
-4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCEREGUL IONS, i r
`lr� �
��05
Re -roofs
Type of Roof
yP
Signature ofApplicant/Contractor Da
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardous material
as defined bythe Cupertino Munici al Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)?
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 [in
L have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Heallh&Safety Code, Sections 25505,25533 and 25534. 1 understand that ifthe building
does not currently have a tenant, that it is my responsibility to notify the occupant Of the
requirements whichasst be me prior to issuance of a certificate of Occas ancy,
Signature of Applicant Date
�/1/1 l(/� I�..�� 5 D 09
All roof coverings to be Class 'A" or better
Owner or authorized agent