09030127CITY OF CUPERTINO
PERMIT
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BUILD ING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20800 VALLEY GREEN DR #489
TBD - TO BE DETERMINED
09030127
OWNER'S NAME:
PERMIT ISSUE DATE
B
0 0 9
PHONE:
SANBAITVINO CONTROL NO.
ARCHITEC IENGTNEER:
BUILDING PERMITINFO
BLDG ELECTPLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
lob Description
hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Scorcean
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
effecDivision3mfdteHusincssandProfcssionsCadc,andmyliccnscis
in full force and effect.
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
Conti
Date Contractor
Dam Contractor
ARCHITECTS DECLARATION
COMMENTS.
I understand my plans shall be used as public records
(DOUBLE FEES)
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt Gum the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
Law 9
that he is licensed pursuant to the provisions of the Contractor's License (Chapter
(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
h 100
N
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 ($500).
32609040 .489
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
(1 P
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li.
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractors) licensed pursuant to the Contractoes
License Law.
❑ I am exempt under S .e. B & P C fo this ason
Owner VV�Date d
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued. .
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy number am:
Carrier.Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit Is forone hundred dollars ($I00)
or less.)
I certify that in the performance of the work for wh''ch this permit is issued, I shall not
'
employ any person in any mannersoo Yccgmc�bjee;Nehthc Workers Compensation
Laws of California. at / Tis G1,Y ^
Applicant '� ' -IA -� —
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Codc, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
)
CONSTRUCTION LENDING AGENCY
i I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
L-endees Name
L.endees Address
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 state laws relating to
4 building canstructien, 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 Iiabilides, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
+ APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON OINT
Issued b :
y Date O
SOURCE REGULNS.
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-
)AAI A lid AAtl�
Re -roofs _
Type Of ROOF
SignatdeofApplicam/Contraclor (— DAe
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)?
Leo
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?
E] Yes u
1 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 occupant of the
`5�uirements which ASL be met pr Io i ce of a,Cctlifhcatc of Occup ey.
Signature of Applicant Date
► V l A & a �A� 0 �
All roof coverings to be Class'n" or better
Owner or authorized agent