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CITE' OF CUPERTINO
DIVISION PERMIT
�TR�iGTC'1�Z�URM�N..:
BUILDING
BUILDING ADDRESS:
PERMIT NO.
20875 VALLEY GREEN DR #47
TBD — TO BE DETERMINED
187
OWNER'S NAME:
PERMIT ISSUE DATE
2009
PHONE:
S A CONTROL NO.
ARCHITEC rfENGiNEER:
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
withSectionndeffofDivision3oftheBusinessandProfcssionsCodc,andmyliccnscis
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
in full force and effect
License Class Lie.
Dam Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITECTS DECLARATION
COMMENTS.
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 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
License Law 9
that he is licensed pursuant to the previsions of the Contractor's (Chapter
(commencing with Section 7000) of Division 3 of the Business and Profcasions Calc) 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 penally of
net more than rive hundred dollars ($500).
32609064 .4 7
❑ 1, 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 does not apply to an owner of
9 P
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
V1, 4y `• 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 Contractor's
License Law.
❑ I am exempt un er Sea _ , B & P C or thi reason
Owner ��1` �� A�.r�. Dale 6
WORKER'S COM ENSATION DECLARATION
I hereby affirm under penally of perjury one of the fallowing declarations:
❑ 1 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, 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 Worker's 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 for one hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner t ,bem s 'ect to the Workers' Compensation
Laws of California. D
t
Applicant r . AA A
NOTICE TO APPLICAN : If, after making tn�ificate 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.)
Lendets Name
Lender's Address
1 certify that 1 have read this application and state that the above information is
+ correct. 1 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
j 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
Issued by: Date (per
SOURCE REGU ATIONS
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t,r -1— V1..�
I
Re -roofs _.
Type of Roof
Signat re o Applicanl/Contrector Date
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
Code, Section 25532(a)?
Yes kp!rNo
All roofs shall be inspected prior to any roofing material being installed.
E]
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?
ke�No
❑Yes
1 have read the hazardous materials requirements under Chap er 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that tribe building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which h st be me priorto i u co or a Certlfhcmc oroc c pan
Signature of Applicant Date
�'"""`'` S� 6�All
roof coverings to be Class',n" or better
'
Owner or authorized agent Date