09030111CITE' OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20800 VALLEY GREEN DR #447
TBD - TO BE DETERMINED
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
A CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMrrINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with orrceand>Uflect. vision3oCtheBusinessandProfessionsCodc,andmyliccnseia
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
Da tcanCass Li Coe.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 alarm that I am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, 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 for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
$Cj= Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1 00
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 penalty of
not more than five hundred dollars ($50o).
32609040.447
® I, as owner of this property, at my employees with wages as their sole compensation,
Required Inspections
e's fl p
will do the work. and the structure isnotimendedoroffered for sale (Sec.7044,Business
and Professions Code: The ContractorLicense Law does not apply to an owner of
property who builds or improves thereon, and who does such workhimseifor 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
sale.
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's U.
copse 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 for thisVeavan
Owner �LY L�'_%Pe
WORKER'S COMPS SATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insum for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for rho 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 am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section aced not be completed ifthe permit is for one hundred dollars (S100)
or less.)
I certify that in the perfamianme of thew for w ich this permit is issued. I shall not
employ any person in any manner o e bj t Workers' Compensation
Laws of Caltfomia, v - _
Applicant _ T_ _l/J .L .• �. __
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 deemed rawked.
h
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, Civ. C.)
Lender's Name
Lender's Address
y I certify that I have read 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 hemby authorize representatives of this city to enter upon the
h above -mentioned property, for inspection purposes.
8 (We) agree to save, indemnify and keep harmless the City of Cupertino against
y liabilities, judgments, costs and expenses which may in any way accrue against said City
"^*.
in consequence of the graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/ �
Issued by: Date L Y .
SOURCE RE—GULA
-.
Re -roofs
Type of Roof
�' �` (► tti �.tA .,� 5
Signature o AppiicaoUContraetorAP
D
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.
(] Yes ®No
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?
0Yes 0No
I have mad the hazardous materials requirements underChapter6.95 of the Califer-
nia Health & SafctyCode, Sections 25505, 25533 and25534. I understand thmif the building
dots not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which t be mot prjar to, a�C a Cenilicare oC
of Applicant Date
�cy-Signature
All roof coverings to be Class`,'1°r or better
Owner or authorized agent