09030125ao�
CCU
I< a
�z
;CCF'u
,wC
10. 1.
:8e
bac
ExCc
v5:
i
I
�oe
ix ~
W
a
�f
UC
�E
o
H G
U `s
r
CI FY OF CUPERTINO
BUILDING DIVISION PERMIT�iTQ���•
BUILDING ADDRESS:
PERMIT NO.
20800 VALLEY GREEN DR #488
TBD - TO BE'DETERMINED
09030125
OWNER'S NAME:
PERMIT ISSUE DATE
29119
PHONE:
SAN ARY CONTROL NO.
ARCHITECGENGINEER:
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 ScorceandafecDivisian3oftheBusiness and Professions Code, and mylicense is
IINSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
in full force and cttecL
License i
E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK
Date Contractor
DaCont
Da
ARCHITECTS DECLARATION
COMMENTS.
1 understand my plans shall be used as public records
( 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 703 1.5, 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
License Law 9
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
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 ($500).
32609040 .488
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q P
will do the work, and the structure is not intended oroffered for sale (Sec.7044.Business
and Professions Code: The Contractors 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
V1, I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li.
cense Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such pmjects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sea B & P C For is on
n - t 4
Owner • t/`'�`� Date J
T-4
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure Cor 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 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 it the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of th work fAr which this permit is issued, I shall not
employ any person in any manna be s ' at to the Workers' Compensation
Laws of Calif, ate
Applicant
NOTICE TO APP C NT: If, after making this cr ifica a of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Coda you must
forthwith comply with such provisions or this permit shall be deemed revoked,
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.)
Lenders Name
Lenders Address
I certify Oat 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
{ building conswcdon, and hereby authorize representatives of this city to enter upon the
above-mentioned pmperty for inspection purposes.
(We) agree to save, indemnity and keep harmless the City of Cupertino against
j liabilities, judgments. costs and expenses which may In any way acerae against said City
in consequence of the granting of this permit,
a APPLICANT UNDERSTAND NO WILL COMPLY WITH ALL NON- DINT
�r
Issued by: Date
SO CE REGUL ONS. /
--
Re-roofs _
Type of Roof
Signature o Applicant/Comractor D tc
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)7
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?
1-1 Yes U 1*vm
I have read the hazardous materials requirements under Chap tar 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 occ ant o the
mqu' hich ibmelXorto isance of a CGniricam of 0
e
S—
Signature of Applicant Date
Al, , 6
All roof coverings to be Class'n" or better
'
t
Owner or authorized agent Date