09030104 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
20800 VALLEY GREEN DR #442 TBD - TD BE DET09030104
OWNER'S NAME: PERMIT ISSUE DATE
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AONE: ANItA CONTROL NO.
ABUILDING PERMIT INFO
RCHITELT/ENGiNEER:
BLDG ELECT PLUMB MECH
0 o a a
q0C LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
� y in full force and effect. INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
E 1= Date Contractor Conti E/M/P' S-SEE PERMIT #09030198 FOR PLAN CK
=^ Datc Contractor
ARCHITEC CS DECLARATION
-� I understand my plans shall be used as public records COMMENTS.
Dwu
�
O l" Licensed Professional
n OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
pO following reason.(Section 7031.5,Business and Professions Code:Any city or county
t.P which requires a permit to construct,alter,improve,demolish,or repair any structure
't'-'- prior to its issuance,also requires the applicant for such permit to file a signed statement
Z ><>< that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
X t- (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 oC
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(5500). 32609040.442
❑1,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(Sec.7044.Business Required Inspections
and Professions Code:The Contractors License Law dors not apply to an owner of q
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,rhe owner-
builder will have the burden of proving that he did not build or improve for purpose of
see
I,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 of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑I am exempt under
Sec. B&P C[`1or tLhis�ason
Owner o 16��v✓\ `^��Bate--�{�-( �—
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workces 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 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 Polity number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I cenifv that in the performance of the w rk fo hich this permit is issued.I shall not
employ any person in any manner so One Workers'CRmpensation
Laws of Califo
Applicant
NOTICE TO APP CAM:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z 0 4CONSTRUCTION LENDING AGENCY
(~i rA I hereby affirm that there is a convection lending agency for the performance of _
> the work for which this permit is issued(Sec.3097,Civ.C.)
WWQ Lenders Name
■04 04 M i cndees Address
U 0 1 certify that I have read this application and state that the above information is
LL►" correct.I agree to comply with all city and county ordinances and state laws relating to
O Ubuilding convection,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (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
►" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N-POINT Issued by: co-
SOU CE REGULA NS.
Re-roofs
Signature of pplicam/Contractor f Ddc
T of F.00f
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
Code.Section25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C]Yes
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 Nu
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 occup t M the
reimincnts whi must be prior ancc of a Cgrtifrcatc of Occ an Signature of Applicant Date
All roof coverings to be Class". 'or better
Owner or authorvcd agent Ditc