09030138CITY OF CUPERTINO
DIVISION PERMIT�1['R§.GTQR�`
BUILDING
BUILDING ADDRESS:
PERMIT NO.
20800 VALLEY GREEN DR #509
TBD — TO BE DETERMINED
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
S A CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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
in full force and effect.
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
License Class Lic.fi
Date Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHrrECCS DECLARATION
1 understand my plans shall he used as public records
COMMENTS.
( DOUBLE FEES)
Licensed
Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct. alter, improve, demolLah, or repair any structure
prior to its issuance, also requires the applicant for such permit to flit a signed statement
License law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$100 O 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjecu the applicant to a civil penalty of
not more than five hundred dollars (s500),
32609040 .509
❑ 1, as owner of the 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 sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
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property who builds or improves thereon, and who does such work himself or through his
awn 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 -
build will have the burden of proving that he did not build or improve for purpose of
sat
I, as 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 contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec , B & P C or lhi reason
Owners Date
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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or Icss.)
I certify that in the performance of the work fol which this permit is issued, 1 shall not
employ an person in an manner so ojb o �b� to the Workers' Com ensadon
P
Yif Y 2 I �. Irl P
Laws of California. etc
o
Applicant A —A , A I,-, - - - - c
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 permit shall be deemed revoked.
1
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructinn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lendees Name
Genders Address
j I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and slate laws totaling to
' building construction, and hereby authorize representatives of this city to enter upon the
1 above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
1 liabilities, judgments, costs and expenses which may in any way accrue against said City
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in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALNON-POINT
Issued by: Date 5� U
SOURCERE ATION . ^^--��
Mn )2 5 � 6 Q
Re -roofs _
'
Type Roof
Signature of Applicant/Comractor t Elate—
HAZARDOUS MATERIALS DISCLOSURE
of
Will the applicant or future building occupantstoro or handle hazardous material
as 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 Ly'Na
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?
[3 Yes jgNu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Heal Ih & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
ct of the
does not currently have a tenant, that it is my responsibility to notify thXa"76
rcme s v Id h usI be me dor to uancc of a Certificate of OcSignature
of Applicant Date
� 56All
roof coverings to be Class','(? .`r or better
owo nthorize�nl