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09030191CITY OF CUPERTINO DIVISION ]PERMIT BUILDING BUILDING ADDRESS: PERMIT NO. 20875 VALLEY GREEN DR #67 TBD – TO BE DETERMINED OWNER'S NAME: PERMIT ISSUE DATE PHONE: S R CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION 701) DOSCfIptlOn I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7006) of Division 3 of the Business and Professions Cade, and my license is in full force andeflect. INSTALL WASHER/DRYER UNITS IN APTS–INCLUDES License Class Lic. # Date Contractor E/M/P' S–SEE PERMIT #09030198 FOR PLAN CK ARCHITECT'S DECLARATION I understand my plans shall be used as public records COMMENTS. Licensed Professional OWNER -BUILDER DECLARATION I 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 swcture prior to its issuance, also requires the applicant for such permit to file a signed statement Contractor's License Law 9 Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the (Chapter (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or 100 that he is exempt therefrom and the 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 rive hundred dollars (s500). 32609064.67 ❑ I, as owner of the property, or my employees with wages as their sole compensation, Required Inspections 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 or 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 Sal l. Las owner of the property, am exclusively contracting with licensed contractors to consiroct 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 Contractor's License Law. C3 am exempt under Sea, B & P C fo this asan Owner WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I 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 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 Workers Compensation Insurance carrier and Policy number are: Carrier. 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 the work for which this permit is issued, I shall not employ any person in any mann s as to ecomr object to the Workcrs' Compensation Laws of Califomia. Data Applicant NOTICE TO APPLICANT: If, after making this Certilicatc-of Exemption, you should become subject to the Workers 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 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 Lender's Address I certify that I have read this application and state that the above information is Correct. l agree to comply with all city and county ordinances and stale 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 liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE REGU TIONS. 1 1 IV I��n�l —� �7r� �.��-. 5 & 6 9 Re -roofs Type of Roof Signature of Applicant/Conoaclor ` Ditto I HAZARDOUS MATERIALS DISCLOSURE 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 Cade, Section 25532(a)? ❑Yes allo 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 Will the applicant or (alum building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? - ❑Yes u I have read the hazardous materials requirements under Chapter 6.95 afthe Califor- nia Health & SafclyCodc, Sections 25505, 25533 and 25534.1 understand that if the building does not currently have a renan4 that It is my responsibility to notify the occupant of the requircmccnisw�hichm�u�,be�meIplP'ortor n ar/F�x Signature of Applicant Date �c/eofa�ccr;neateorO'ca 1/ / l.��i�/""'"\V `r ©�!1' it _ All roof coverings to be Class ,¢� or better Owner o authorized agent Dale