09030112MY OF CUPERTTNO
PERMIT
PERMIT
N�
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20800 VALLEY —GREEN
TBD - T
OWNER'S NAME.
PERMIT ISSUE DATE
PHONE:
S A CONTROL NO.
ARCHr2ECTlEQGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
iwith Section nfulfotceandaffec�vtann3oftheBrtsinossand Professions Code.andmylicense is
INSTALL WASHER/DRYER UNITS IN AP'I'.�i. —INCLUDES
LicDate contractor Crass Contractor
E/M/P' S-SEE PERMIT #09030198 FOR PLAN CK
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
COMMENTS.
( DOUBLE FEES
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby ai'fir a that I am exempt from the Contractor's License Law for the
following mason. (Section 703L5. Business and Professions Code: Any city or county
which requires a permit to construct, alter. improve, demolish, or repair any structure
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 Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
APN Number
Occupancy Type
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not morn than five hundred dollars (M)0
32609040.449
L as owner of the property, or my employees with wages as their sale compensation,
ns
Required Inspections
Ll P
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
License Law does not apply to an owner of
and Professions Code: The Contractor'se
property who builds orimproves thereon, and who does such work himselfor through his
own employees, provided that such imprevements am not intended or offered for sate. If,
however, the building or improvement is said within one year of completion, the owner -
build win have the burden of proving that he did not build or improve for purpose of
sal .
I, as owner of the pmperty: am exclusively contracting with licensed contractors to
cooswct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a conumcuu(s) licensed pursuant to the Contractors
Licenste raw.
Of am crept under SSec. B & P C Car thi reason
Owner �.� h_ �i fins to
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
® I have and will maintain a Cortificatc of Consent to self-insum for Workers Compco-
sation, as provided for by Section 3700 of the tabor Code, for the performance of the
work for which this permit is issued.
[] a have and will maintain Workers 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 am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(1 nis section need not be completed if the permit is for one hundred dollars ($100)
or tens.)
I certify that in the performance of ytorkpfar}vfile thia permit is issued. I shall not
employ any person in any mammr njjii bettaa�mdl the Workers' Compensation
Laws of Califo "a Da —
Applicant Y
NOTICE TO APPLICANT: If after making this Certificate 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 dcemcd revoked.
)
° CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction tending agency for the performance of
the work for which this permit is issued (Sec. 3097, CFv. C.)
y Lender's Name
Lender's Address
I certify that I have mad 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 proposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
I liabilides, 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 (V , J
SOURCE REGUL TIONS.
W - Q A..-w.^ l�
Re -roofs _
Type of Roof
Signature of Appiicant/Contractor If
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mum ' aI 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 No
If a roof Is installed Without first obtaining an inspection, I agree to remove
Will the applicant or future Funding occupant use equipment or devices which
emit hazardous air contaminants defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
®Yes Nc
I have mad the hazardous materials requirements underchapterb.95 of the Califor-
nia Health &SafetyCodc,Seedons25505,25533and 25534.1undcruindthatifthe building
does not currently have a tenant, that it is my responsibility to notify the axupant f the
requirements which m t be mot •or to' nuance of a Ccrtitx:atc of Occu
Signature of Appllcant Date
"A-
All roof coverings to be Class "As' or better
-A" t.
1 Date
Owner or authorized agent