09030084 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � R
BUILDING ADDRESS: PERMIT NO.
20800 VALLEY GREEN DR #403 TBD — To BE DE
OWNER'S NAME: PERnIIT ISSUE DATE
TTRQ -
A2889
O. CONTROL NO.
.-TONE: A
BUILDING PERMIT INFO
ARCHITEC rIENGINEER:
BLDG ELECT PLUMB MECH
v p p LICENSED CONTRACTOR'S DECLARATION 70b Description
V
p I 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
;2y in full force and effect. INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
CDnZ-a Date Contractor
Lle•x E/M/P' S-SEE PERMIT #09030198 FOR PLAN CK
Dam Contractor
ARCHITECTS DECLARATION COMMENT 3.
-a 1 understand my plans shall be used az public records
�yU
o y Licensed Professional
OWNER-BUILDER DECLARATION
vi
I hereby affirm that 1 am exempt from the Contractor's License Law for the
L
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
,-.9 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 rile a signed statement Valuation
- < that he is licensed pursuant to the provisions of the Contractor's Incense Law(Chapter 9 Sq.Ft.Floor Area
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or $100
y 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 live hundred dollars(M). 3260904D .403
❑I,as owner of the property,or my employees with wages az their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044.Business Required Inspections
and Processions Code:The Contractor's License Law does not apply m 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-
buildXwin have the burden of proving that he did not build or improve for purpose of
7sa ,.
I,az owner of the property,am exclusively contracting with licensed contractors to
construct 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 contraaor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec B do P C fo this n
Owner x,19=--�
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑f 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 Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred dollars(2100)
or Icss)
I certify that in the performance of the w rk for Iffich this permit is issued,1 shall not
employ any person in any manner salrm ➢omstrlfie the Workers'Compensation
Laws of Calif o7 tNu JJ bb ((11
Applicant ,�
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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z^' CONSTRUCTION LENDING AGENCY
(^'y►�. I hereby affirm that there is a construction lending agency for the performance of
Qa. the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Lender's Address
V C) 1 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
0 V building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments.costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
� 4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b3. 5. cp
SOURCE REGULA IONS. P
`l/Yl. .dA. SA J I ,( 6 9_ Re-roofs --
Signature if-Applicant/Contractor —bate F 'I Of]�OOf
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
az 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.
❑Yes l�S 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 r iaterials for inspection.
District?
❑Yes ( u
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health dr Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the Otto ant of the
req . m is which t be met prior dance of a Certificate or parr Signaturf:of Applicant Date
5 All roof coverings to be Class'R"or better
Owner or authorized agent ate