09030092 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � :
PERMIT NO.
BUILDING ADDRESS:
20800 VALLEY GREEN DR #423 TBD — To BE 2EMEMINED- 09030092
PERMIT WUE DATE
OWNER'S NAME:
JAtft'A1QY�90,?a 9 9 CONTROL NO.
rlONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
ad
p C LICENSED CONTRACTOR'S DECLARATION JOb Description
U 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
4Z with Section 7000)of Division 3 of the Business and Professions Code.and my license is INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
H in full force and effect
License r
DContractor E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
=f Dam
ARCHITECTS DECLARATION COMMENT 3.
1 understand my plans shall be used as public records
�yU
OI— Licensed Professional
N OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's Liccnse Law for the
p O following mason.(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 signed statement Valuation
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 1 O 0
a that he is exempt therefrom and the basis for the alleged exemption.Any violation of
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(M). 32609040 .423
❑I,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 Conuactoes 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 sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder win have the burden of proving that he did not build or improve for purpose of
sale.
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Comractoes U.
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractor's
License Law.
❑1 am xempt unde Sec. B&P C fo this aeon
Owner 1P i�4"^ '" /�"ne� Ito
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's 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 performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Polity number ate:
Carrier. 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 Icss.)
I certify that in the performance of the we for this permit is issued,1 shall not
employ any person in any manner so c chick the Workers'Compcnsaton
Laws of California.D
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of eruption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
F-t I hereby affirm that there is a construction lending agency for the performance of
a the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lendces Name
az Lender's Address
1 certify that 1 have read this application and state that the above information is
LUL correct 1 agree to comply withal[city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
�I) liabilities,judgments,toss and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO -POINT Issued b,':
SOU E REGUL TIONS.
5 Re-roofs -
Signatreof App icant/Contractor D to T of]hoof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mun cipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? All roof, shall be inspected prior to any roofing material being installed.
C]Yes No
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 u
1 have read the hazardous materials requirements under Chapter 6.95 of to Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant M the
requirements wnscru�met�n;°rw�ssa� �te°r� a 9 Signature:of Applicant Date
V �,JLAc All roof coverings to be Class'��''or better
Owner or authorized agent D