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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