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CITE' OF CUPERTINO
PERMIT
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BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20800 VALLEY GREEN DR #486
TBD - TO BE DETERMINED
09030123
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SAN A Y O. CONTROL NO.
ARCHI'IECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
70b Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
ecDivision3afthe Business and Professions Code, and mylicense is
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
in full Coree and effect.
inullrorcnnde
License
E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK
Dam Contractor ontr
D
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 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
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 Conlmclor's License (Chapter
(commencing with Section 7000) of Division 3 or the Business and Professions Cade) 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 penally of
not more than five hundred dollars ($500).
32609040 .486
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
9 P
will do the work, and the structure is not Intended oroffered ter sale (Sec.7044,Business
and Professions Code: The 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 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 or
salt.
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 conuactor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under ec. , B & P C or th' reason
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Owner �J✓ V
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insum far 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 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 forone hundred dollars ($100)
or less.)
I certify that in We performance of c we for which this permit is issued. I shall not
'
employ any person in any mannyrs �as�b�corb ccl to the Workers' Compcnsauon
AA vv
Laws of California. Dale 11
Applicant
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.
a CONSTRUCTION LENDING AGENCY
+ I hereby affirm that there is a construction lending agency for the performance of
y the work for which this permit is issued (See. 3097, Civ. C.)
Lendees Name
Lcndees Address
1 certify that 1 have read this application and stale Wal the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
y 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
1 liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO POINT
Issued by: Date 1�s La
SOURCEREGUL ONS. -
Q—
Re -roofs _
Type of Roof
Signature o Applicant/Contractor ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupanlstorc or handle hazardous material
as defined by the Cupertino MIInICI al Code. Chapter 9.12, and the Health and Safely
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
r-1 Yes o
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?
❑Yes
I have mad the hazardous materials requirements under Chaplet 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that lf thc building
does not currently have a tenant, that it is my responsibility to notify the cupanr f thc
requirements which or be met priori uance of a Certificate of O_cm
Signature of Applicant Date
All roof coverings to be Class' j`` or better
Owner or author zed agent Dae