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CITY OF CUPERTINO
PERMIT�R�l�
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #254
TBD — TO BE DETERMINED
09030120
PERMIT ISSUE DATE
OWNER'S NAME:
-RET
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BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) ofDivision 3 of the Business and Professions Code, and my license is
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
in full force and effecL
License Class Lic.N
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
Dam Contractor
ARCHITECTS DECLARATION
COMMENT S
1 understand my plans shall be used as public records
i
.
i Licensed Professional
OWNER -BUILDER DECLARATION
1
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Cale: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
m prior to its issuance. also requires the applicant for such permit to file a signed statement
9
Sq. Ft. Floor Area Valuation
e that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
3 (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 violation of
Section 7031.5 by arry applicant for a permit subjects Lite applicant to a civil penalty of
APN Number Occupancy Type
not more than fire hundred dollars (M).
32609041 .254
❑ I. as owner of the property. or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (See. 7044. Business
Required Inspections
and Professions Cade: The Conuactoes License Law dors 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. 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
71, 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 themon, and.
who contracts for such projects with a contractors) licensed pursuant to the contractor's
License Law.
E3 ISM exempt under Sec (� q _ B & P C�f�r t/h reason
"n/InJC i �^�.�/�Dtle
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Owner ' /A 9
WORKER'S COMPENSATION DECLARATION ` 1
I hereby affirm under penalty of perjury one of the following declarations:
❑ f 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 Lite Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance prier and Policy number am:
Carver; Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section meed not be completed if the permit is for one hundred dollars ($100)
or less)
I certify that in the performance of N work for which this permit is issued, l shall not
employ any person in any manner w m t to the Workers' Compensation
Laws of California D
Applicant
NOTICE TO APPLICANT: If, after making this Ccrm tate 01 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.
-4 CONSTRUCTION LENDING AGENCY
A
I hereby affirm that there is a construction lending agency for the performance of
> the word for which this permit is issued (Sec. 3097, Civ. C.)
aLender's Name
Lender's Address
3 1 certify that I have read this application and stale that the above information is
:4 correct. I agree to comply with all city and county ordinances and state laws relating to
building concoction, 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
n liabilities, judgments, costs and expenses which may in any way scenic against said City
in consequence of the granting of This permit.
Date
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I APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:
SOURCE REGUL TIONS.
M --� 5 �(
Re -roofs
Signalrre o ApplicanUContractor r6tc
HAZARDOUS MATERIALS DISCLOSURE
T of 1:oof
Type
Will the applicant or future building occupant store or handle lumardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
fi
Cale. Section 25532(a)?
All shall be inspected prior to any roofing material being installed.
❑Yes ❑No
roofs
If a roof : s 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?
❑Yes ❑No
1 have mad 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 ratify the occupant of the
re uiremcnts which m st be met pri to is�,ancc of certificate ofOccu aney. Signature of Applicant Date
in �` 5' 1 1 0
All roof coverings to be Class 'Aj ' or better
Owner or authorized Scent - Dale