09030117 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � ..
PERMIT NO.
BUILDING ADDRESS:
20800 VALLEY GREEN DR #465 TBD - TO BE DETERMINED 09 117
PERMIT ISSUE DATE
OWNER'S NAME:
UBS SA AIry Nb CONTROL NO.
.TONE:
BUILDING PERMIT INFO
ARCHI7ECTIENGINEER: BLDG ELECT PLUMB MECH
a 0 0 a
p C LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 70W)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 Li Contractor
E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK
p Date
3 Lu ARCHITECTS DECLARATION COMMENT;.
1 -4 I understand my plans shall be used as public records
DWI; (DOUBLE FEES)
U.in Licensed profcssional
n H OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
e m 8! which requires a permit to construct.alter,improve,demolish•or repair any structure
a In prior to its issuance,also requires the applicant for such permit to rile a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of due Contractor's License Law(Chapter 9 Sq
t- (commencing with Section 7000)of Division 3 of the Business and Profcssians Codc)or $100
4 5 2 that he is exempt therefrom and the basis for the alleged exemption.Any violation of3. 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($500). 3260904) .465
0 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not inte.ndedoroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such warp 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
sa v
CSI/,Ias 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 contractor(s)licensed pursuant to the contractors
License Law.
0 1 am exempt under Sec. B&P C fa this son
Owner ' , ^ - Date b
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
0 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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Mis section reed not be completed if the permit is for on hundred dollars($100)
or less.)
I certify that in the performance of work for which this permit is issued,I shall not
employ any person in any mann %b.10
ct to the Workers'Compensation
Laws of California.Da
Applicant
NOTICE TO APPLICA :If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[ rN. I hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Z
Lender's Address
I certify that I have read this application and slate that the above information is
LUL COrCCL 1 agree to comply with all city and county ordinances and state laws relating to
8 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
�.4 liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
0-4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b):
LP
SOURCE REGULANgQINS.
1,JA X 5 L —9 Re-roofs -
Signa reofApplicant/Contractor . T of Roof
MATERIALS DISCLOSURE Type
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 Idrvo
Will the applicant or future building occupant use equipment or devices which
If a roof .s installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r.laterials for inspection.
District?
0 Yes MA
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which mustAc met po,A.n rssuaf a Ccri6calc of Occupancy. Signaturf:of Applicant Date
___v_� 1^ All roof coverings to be Class';.''or better
Owner or authorized agent Date