09030136 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � R��
BUILDING ADDRESS: PERMIT NO.
20800 VALLEY TBD - T) BE JaETRRMTT\TRn rignini -A
OWNER'S NAME: PERMIT ISSUE DATE
/2809
JN S CONTROL NO.
ABUILDING PERMIT INFO
RCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
V 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
� y in full force and effect. INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
EenscClaaa
a Date Coma E/M/P' S-SEE PERMIT #09030198 FOR PLAN CK
M' DaARCHITECTS DECLARATION
e I understand my plans shall be used as public records COMMENT 3.
Licensed Professional (DOUBLE FEES)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
COO following reason.(Section 7031.5,Business and Professions Code:Any city or county
e m 9 which requires a permit to construct,alter improve,demolish,m repair any structure
prior to its issuance,also requires tho applicant for such permit to file a signed statement
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 iq.Ft.Floor Area Valuation
YH (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
00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than fire hundred dollars 4500). 32609040 .506
❑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 Required Inspections
and Professions Code:The Contractor's License Law dots not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or thmugh 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 will have the burden of proving that he did not build or improve for purpose of
sa
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U.
cense law docs 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.
❑I am exempt under Sec B&P C for thi reason
Owner W"—d" Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑f have and will maintain a Certificate of Consent to self-insure for workers 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 am:
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 less.)
I certify that in the performance of the woo for tch this permit is issued,I shall not
employ any person in any manner so as�hgcgmc�bI toihe Workers'Compensation
Laws of California,qct 11 (C�� ((JJ�1
Applicant —*
NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cock.you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
[~-r CA I hereby affirm that there is a construction lending agency for the performance of
pC> the work for which this permit is issued(Sec.3097,Civ.C.)
f3a Q Lendefs Name -
0 z Lender's Address
U O I certify that I have read this application and state that the above information is
LL t-r conccL l agree to comply with all city and county ordinances and state laws relating to
C)Vconstruction.building consction.and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. OCV
Date APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: S. Q.
SOURCEREGULA ONS.
✓�^"^��- S to bQ Re-roofs
Signatulm of Applicant/Contractor DaLb T of R sof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muni'pal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs;;hall be inspected prior to any roofing material being installed.
❑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 m 3terials for inspection.
District?
❑Yes EJNu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&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 occu ant of thc
requi mens which be met ' r to uance of a Certificate of o<span . Signature of Applicant Date
�' All roof coverings to be Class'A!'or better
Owner or authorized agent oro