09030090UY OF CUPEKILNO
BUILDING DIVISION PERNUT
OWNER'S NAME:
ARCH]TECTIENGINEM,
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70DO) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class _ Lie. #
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the I Contractor's License Law for the
following mason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit 10 munartiC4 alter, improve, demolish, Or mindf any structure
prior to its issuance, also requires the applicant for such permit to file asigned statement
that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9
(commencing with section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7o31.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($5W).
Ej 1. 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
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 am not intended or offered for side. If.
i however, the building or improvement is sold within one year of completion. the owner -
I builder will have the burden of painting that he did not build or improve for purpose of
16 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors L4.
cc= Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a contracuu(s) licensed pursuant to the Contractor's
License LAW.
0 1 am exempt under Sez B tit PCfor this an
Owner
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
C] I have and will maintain a Certificate of Consent to self-lasum for Worker's Ccmpen
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
C1 I have and will maintain Workees 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
Mat section need not be completed if the permit is femme hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so 15 3tmc)msjs%dj'ecekthe Workers' Compensation
Laws Of California
Applicant -
NOTICE To AP CA if, after ihaldng 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 or
I the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Leader'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 lam relating to
building construction, and hereby authorin representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and " harmless the City of Cupertino toast
liabilidesJudgments, costs and expenses which may in any way accrue against said City
in consequence or the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE REGULATIONS,
Signature ol'ApplicanuContractor Dafil
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined 'y b the Cupertino Mom- I Code. Chapter 9.12, and the Health and Safety
Code, Scd., 25532(a)?
0 Yes 0
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
District?
0 Yes No
PERMIT NO.
agninago
PERMIT ISSUE DATE
CONTROL NO.
BUILDING PERMIT INFO
BLDG
ELECT
PLUMB
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUD
E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS. I
Ft.
F- APN Number Occupancy Type
32609040.407
Issued by:
Re -roofs
Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
I have read the hazardous materials requirements underChapter6.95 of the CAlifor-
niaHealth & SafetyCod;_ Sections 25505.25533 and 25534.1 understand that if the building
does not curmndy have a tenant. that it is my responsibility to notify the occupant or the
rcywts whitmust be met prior issuance ofa Certificate of Occoancy
f Signature of Applicant Date
01 A4 All roof coverings to be Class %` or better
Owner or authorized seen[ cite