09030121 CITY OF CUPERTINO �r
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
20800 VALLEY GREEN DR #481 TBD — TD BE DETERMINED 090101 21
OWNER'S NAME: PERMIT ISSUE DATE
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HONE: S A CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 700(1)of Division 3 of the Business and Professions Code,and my license is
��oy in full force and effecL INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
D gj Z'_ License Class Lic.N
—a Date Contractor E/M/Pt S-SEE PERMIT #09030198 FOR PLAN CK
ARCHITECTS DECLARATION
UI understand my plans shall be used as public records COMMENT 3.
icy Licensed Professional (DOUBLE FEES)
y 3 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
in o following mason.(Section 7031.5,Business and Professions Code:Any city or county
,e m Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 SQ.Ft.Floor Area Valuation
yt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and Ute basis for the alleged exemption.Any violation of $100
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(M). 3 2 6 0 9 0 4 ).481
0 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(See.7044,Business Required Inspections
and Professions Code:The Contractor's License Law dors reet apply to an owner of Q
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
salc r
I,as owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
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.
0 I am exempt under Sec —.1` /�Wl/��ltB&P C�for th/is�n
Owner 4' e�(—
WORKER'S COMPENSA77ON DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insure for 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.
0 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:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is foram hundred dollars($100)
or less)
I certify that in the performance of the ork for hich this permit is issued.I shall not
employ any person in any manmr o c b' to the Workers'Compensation
Laws of California.Datc
Applicant
NOTICE TO APPLICA .If,after making this Certificate Tf Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
Gi the work for which this permit is issued(Sec.3097,Civ.C.)
a Q Lendces Name
Landers Address
V 0 1 certify that 1 have read this application and stare that the above information is
LL correct.l agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city m enter upon the
Uabove-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
n",a con liabilities,judgmcns,Coss and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
t" APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON OINT Issued by: Date U
SOU CE REGULAONS.
S Re-roofs
Signature of Applicant/Contractor Doti--T-
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munici at Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)?❑Yes o All roofs s Iall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new me terials for inspection.
District?
[I Yes 94.
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 occupani of the
regal m nwhich be metTto i ct:of a Certificate of Occas Signature(f Applicant Date
All roof coverings to be Class'A"or better
Owner or authorized agent I Da