09030097CITE' OF CUPERTLNO
DIVISION PERIVIIT
BUILDING
BUILDING ADDRESS:
PERMIT NO.
20800 VALLEY REEN DR 7
TBD — TO BE DETERMINED
OWNER'S NAME.
PERI♦IIT ISSUE DATE
PHORK
A I A O. V V CONTROL NO.
ARCHrrBcT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONtRACTOitS DECLARATION
Job Description
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
in full force and effect.
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
Date lass Co *
Date Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHi1ECTS DECLARATION
I understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt Gem the Contiactues License Law for the
following reason. (Section 70313, 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
Contractor's Liconsc Law 9
Sq. Ft, Floor Area
Valuation
that he is licensed pursuant to the provisions of the (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
32609040.427
® L as owner of rile property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sate (See.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 himself or through his
own employees, provided that such improvements are not intended or offered for sate. 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
tKasowner of the property, am exclusively contracting with licensed contractors to
constmct the project (Sec. 7044. Business and Professions Code:) The Contractor's 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 Contractor's
License Law.
0 I am exempt under Seo. �} B & P C for dils on
Owner yr ,-Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I have and will maintain a Certificate of Consent to self -insure for Woftes Compen-
sation, as provided for by Section 3700 of the Labor Code, for die performance of the
work for which this permit is issued.
1 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 arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.) _
I certify that in the performance of rho w rk to in h this permit is issued, I shall not
employ any person inany manner so err sptaiest to the Workers' Compensation
Irre
'
Laws of CaiifoTj�I& Date --� j
Applicant Lir L t =e.3 zL4e0.n:a__
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 pecnsit 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.)
Lender's Name
Lender's Address
j I cadfy that I have read this application and state that the above information is
cmrecL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
i above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j 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 -POINT
Issued by; Date ,
SOURCE REGULA GNS,
Re -roofs _
Type of Roof
D9
Signatbd a pplicant/Contvactor I Duo I
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mumci I Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes a
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupam use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? /
[jYesTu
I have mad the hazardous materials requirements underChapwr6.95 of the Califor-
nia Hcalth & SafetyCodc, Secrioms 25505.25533 and25534. l understand thatif the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirement% whic' `trst be me nor uanco of a Certificate of Oc+aacy
full!'5161 6�
Signature of Applicant Date
All roof coverings to be Class''` or better
�
Owner or authorircd agrnt