09030108 CITY OF CUPERTINO C.
BUILDING DIVISION PERMIT Pitdwi ��
PERMIT NO.
BUILDING ADDRESS:
20800 VALLEY GREEN R #444 TBD — TI BE
PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
.ONE:
BUILDING PERMIT INFO
ARCHITECUENGiNEF.R: BLDG ELECT PLUMB MECH
(---7
u ve p C LICENSED CONTRACTOR'S DECLARATION Job Description
UI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
in full force and effect. INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
; D
�� LicenseClassCo tractor E/M/P' S-SEE PERMIT #09030198 FOR PLAN CK
=F Date
ARCHITECTS DECLARATION
-� I understand my plans shall be used as public records COMMENTS.
(DOUBLE FEES)
3:U.InLicensed Professional
0, OWNER-BUILDER DECLARATION
AN.d
I hereby affirm that I am exempt from the Canlractars License Law for the
g o O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K o 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 Valuation
—?< that he is licensed pursuant to the provisions of the Contractor's Liccase Law(Chapter 9 Sq.Ft.Floor Area
X F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $100
A that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(s500). 32609040.444
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work4 and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors 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.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
Ksa
as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner or property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
D[a exem t undo Sec B&P C r i reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insum for Workers 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 I 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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Phis section need not be completed if the permit is for one hundred dollars(5100)
or Icss.)
I certifv that in the performance of the rk f which this permit is issued,I shall not
employ any person in any manner so brfo o the Workers'Compensation
Laws of California. tc
Applicant
NOTICE TO APPLI ANT:If,after making this Ceniticatc 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 0 CONSTRUCTION LENDING AGENCY
(.r C/) 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.)
W Lenders Name
� Lenders Address
1 certify that I have read this application and state that the above information is
LUL correct.1 agree to comply with all city and county ordinances and state laws relating to
0Ubuilding construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
In 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 / n
r-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- OINT Issued b): lX--0—a
SO RCE REGUL ONS.
S Re-roofs -
Signature of Applicam/Comractor I Da T of Roof
HAZARDOUS 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
Cole,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 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
MR hazardous air contaminants as defined by the Bay Area Air Quality Management all new r iaterials for inspection.
District? /
❑Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 undcrstarud that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant o the
reyuiremcnts whist ttst be met 'or to iss of a Certificate of Occu cy. S ignaturc of Applicant Date
i-�1 -- 91`6 1 o� All roof coverings to be Class" ''or better
Owner or authorized agent � `Date1'