09030114CITY PERTLNO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20800 VALLEY GREEN DR #457
TBD TO BE DETERMINED
-09030114
OWNER'S NAME.
PERMIT ISSUE DATE
PHONE:
s YAkYii6.CONTROL NO.
ARCHrrECTIENCINEM.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section70M) of Division 3 of the Business and Professions Code, and my license is
in full form and effect.
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.
(DOUBLE FEES)
- -
ensedPmfcs�sicnal
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, 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 parsuch permit to rile asigned statement
that he is licensed pursuant to the provisions of the Contructor's License Law (chapter 9
Sq. Ft. Floor Area
Valuation
(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 viola" of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars ($500).
32609040.457
0 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 (See. 7044, Business
and Profession Code: The Contractor's 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 for sale. It,
however, the building or improvement is sold within one year of completion, the owner -
builder will have am burden of proving that he did not build or improve for purpose of
;Y1.1 contracting with licensed contractors to
as owner of the property, am exclusively
ce met the project (sit- 7044, Business and Professions Code:) The Contractors U-
cartse Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a cantractor(s) licensed pursuant to the comractoes
License Law.
0 1 am exempt under Sec. B & P C for 11
Owner Le is
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
[3 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.
0 1 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 am:
Carrier: Policy No..
CERTIFICATE OF EXEMFnON FROM WORKERS"
COMPENSATION INSURANCE
(This section need not be completed if the permit is foram hundred dollars ($100)
or less.)
I certify that in the performance of the work f, which this permit is issued, I shall not
employ any person in any manmrs okeco
W& to the Workers' Compensation
Laws of Califerni D-1- .
Applicant
N'T 7you .ld
NOTICE TO APPLICAIf. after making thYs Certificate 4 Excm;z
become subject to the Workees compensation provisions of ma Labor Code, you must
forthwith comply with such provisions or this permit shall be deenuixt revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is Issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that I have mad this application and state that the above information is
cormcL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorim representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
I liabilities, judgment$, costs and expenses which may in any way accrue against said City
in consequence of the grinding or this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-POI
Issued by: Date
SOURCE REGULNIONS.
Re -roofs
Type of Roof
5 1
W LA_V'�_�. 3vk& 91 6q
Signature iii'Applicam/Contractor k_ Ejatti__
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)?
All roofs shall be inspected prior to any roofing material being installed.
0 Yes ONo
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
ernh hazardous air contaminants as defined by the Say Area Air Quality Management
all new materials for inspection.
District?
13 yes ONo
I have mad the hazardous materials requirements under Chaptcr695 of the Califor-
nia Health & SaletyCode, Sections 25305,25533 and 25534. 1 understand thatif the building
u
does not currently have a tenant, that it is my responsibility to no ify the occu of the
mq . eats whit be prior toissuance ofa CortifiegItc: of Occullancy,
Signature of Applicant Date
=must
W ell A'11^1 5 [A
All roof coverings to be Class or better
I Dak
Owner or authorized agent