09030129joc
?W
L
0.
LW
:°a
�qC
u^u
Z
zFc
C
z,
—iv
h-
134
W
Z:) �2
UC
1*. 1-
0-4
0-4 CO
V
1 -
CITY OF CUPERTINO
BUILDING DIVISION PERMIT�T�•
BUILDING ADDRESS:
PERMIT NO.
20800 VALLEY GREEN DR 4490
TBD — T BE DETERMINED
nc)n_�nl 29
OWNER'S NAME:
PERMIT ISSUE DATE
PHORPS
A CONTROL NO.
ARCHITECr/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
0 0
LICENSED CONMACrOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700(1) of Division 3 of the Business and Professions Code, and my license is
in full farce and effect.
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
License Class Lic. 8
Date contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHrrECPS DECLARATION
1 understand my plans shall be used as public records
COMMENTS.
( DOUBLE FEES)
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (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 rile 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
10 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 subjects the applicant to a civil penalty of
not more than five hundred dollars ($501).
32609040 .490
❑ I, as owner of the property, or my employees with wages as their solo compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
The
and Professions Code: 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 are not intended or offered forsale. 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 or
sale.
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 contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sea , B & P C for thi reason
Owner A 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 Workees Compen.
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 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 Worker's Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the permit is forone hundred dollars ($1110)
or less.)
I certify that in the performance of theworiCtfor hich this permit is issued. I shall not
'
employ any person in any manner so ore sr a the Workers' Compensation
taws ofCalifomia D-
Applicant t !: "r ��
NOTICE TO APPLICANT: If, alter 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 invoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Landees Address
j I 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 slate laws relating to
' building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities,judgments, 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 A L N N -POINT
Issued by: Date lJ
SOURC REGULAT NS. n
Cf
n
Re -roofs
Type of Roof
Signature of Applicant/Contractor 6atc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
V.
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
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?
No
❑ Yes
I have read the hamrtious materials requirements under Chapter 6.95 of the Caliror-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building
does not currently have a tena that it u my responsibility to notify the occupant or the
rcre ms whi mast be lP riot o issuance of'a Certificate of p ca x
Signature of Applicant Date
AA.t.r..i / A64
All roof coverings to be Class or better
Date
Owner or authorized agent