09030099CITY OF CUPERTINa
BUILDING DIVISION PERMIT :s
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BUILDING ADDRESS:
PERMIT NO.
208
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OW NEWS NAME:
PERMIT ISSUE DATE
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A CONTROL NO.
ARCHrfBCTteNGINEER:
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 7000) of Division 3 of the Buslauss and Professions Code, and my license is
in full force and affect
INSTALL WASHER/DRYER UNITS" IN APTS—INCLUDES
License Class Lie. #
Date Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHrrECTS 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 Contmetot's License Law for the
following reason. (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 signal statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
8100
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
32609040.434
® L as owner of the property, or my employees with wages as their sale compensation,
Required Inspections
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will do the work, and the structure isnot intended oroffered for sale (Sec.7044.Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himselfor 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 at improve far purpose of
sat �f
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 Li -
come Law does not apply to an owner of property who builds or improves; thereon, and,
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
®I am amps urde_r t,S�efo _ B & P C f this n
Owner abate
WORKER'S COMPENS T ON DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
® I have and will maintain a CerGfrcate of Consent to self-insum for Waftes 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 the Labor Code, for the perfotmance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forium hundred dollars (Slo01
or Iess.)
I certify that in the performance of u wa k for which this permit is issued. I shall not
employ any person in any man as c t � bjuct to the Workers' Compensation
Laws of Call fq is Date
Applicant
NOTICE TO APPLICANT. If, after making this Cenificate of Exemption, you should
become subject to the Workcrs Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
i
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction Sending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
i Lender's Name
Lenders Address
g 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 mlating to
° building construction. and hereby authorize reprsentadves of this city to enter upon the
dabove -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
3 liabilities,judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
( APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- OINT
S RCE REGULATIONS.
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Issued by: Date
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Re -roofs
Signature of ApplicantlContracor Da
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
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.
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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
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHcalth & SafetyCode, Sections 25505, 25533 and 25534.1 understand that ifthe building
does not currently have a tenant, that it is my responsibility to notify the cup t of the
mq 're c}nimust be rout of 3 trance afa Certificate of Ccy
Signature of Applicant Date
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All roof coverings to be Class'" or better
Ownuthozed agent