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09030102CITY OF CUPERTINO PERNUT tkir! Mwod BUILDING DIVISION BUILDING ADDRESS: PF4mrr No. 20800 TBD ja_BZ_pB��.. OWNER'S NAME: PERMIT ISSUE DATE PHONE. §'A-1ftA*T`NO" 'CONTROL NO. ARCHITECTIENGINEER* BUILDING PERMIT INFO 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 70W) of Division 3 of the Business and Professions Code, and my ficerne is in full force and effect. INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES License Class _ Lic. # Date contractor E/M/P'S-SEE PERMIT #09030198 FOR PLAN CK ARCHrrECT`S DECLARATION I understand my plans shall be used as public records COMMENTS. Licensed —Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following mason. (Section 70313, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish. or repair any structure Sq. Ft. Floor Area Valuation prior to its issuance, also requires the applicant for such Permit to file a signed statement License Law 9 that he is licensed pursuant to the provisions of the Comractoes (Chapter (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 APN Number Occupancy Type Section 7031-1 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). 32609040.440 0 L as owner of the property, or my employees with wages as their sale compensation, Required Inspections will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business and Profession Code: The Conummur's License Law am not apply to an owner of property who builds orimproves thereon, and who dmimchworithimselforthrough his own employees, provided that such improvements are not intended oraffered fur sate. If, however, the building or improvement is sold within one year or completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of gal sate Ki s owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Cade:) 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. 0 1 am exempt under Sec. B & P C for is re on Owner !�� I WORKER'S COMPENSATION DECLARATION I t I 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 Compim• sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. rl 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 need not be completed if the permit is Corona hundred dollars ($100) or less.) I certify that in the performance of the work which this permit is issued, I shall not employ any person in any manner, in to the Workers' Compensation fr M. Laws ofcalirb i J�' Applic — ,: t CA: A NOTICE TO A13PLICKNT. 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 revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that them is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Landoes Name Lender's Address I certify that I have mad this application and state that the above information is correct, I agree to comply with all city and county ordinances and state laws misting to building construction, and hereby authorize representatives of this city to enter upon the above -mentioned property for inspection purposes. (Wa) agree to save, indemnity and keep harmless the City of Cupertino against I liabilities, judgments, costs and expenses which may in any way accrue against said City : in consequence of the granting of this Permit. 4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-P xT Issued by: Date Le - 09 SOURCE REGUL ONS. 1, Re -roofs Type of Roof Signature oCApplicanti'Contractor ­ -am HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.11 and the Health and Safety Code, Section 25532(a)? ly< All roofs shall be inspected prior to any roofing material being installed. []Yes 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? ®Yes V(No I have read the hazardous materials requirements undzrChapmr6.95ofrho Califor- nia Health& SalaryCodc, Sections 25505,25533 and25534. I understand thatif the building does not currently have a meant. that it is my responsibility to notify the occupant of the mq Imments wht:ust in t pno= issuance of 4 Certificate of Oc Signature of Applicant Date 3 It `CAA IL4,5- 61 All roof coverings to be Classn' or better — Owner or authorized agent , riatc