10050154 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 451 CON"'RACTOR:UBS
PERMIT NO: 10050154
OWNER'S NAME: UBS 20800 VALLEY GREEN DR DATE ISSUED:05/19/2010
NER'S PHONE: 4082530200
CUPIMTINO,CA 95014 1 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.# MECH r— RESIDENTIAL r COMMERCIAL r
Contractor Date
JOB DESCRIPTION: INSTALL WASHER/DRYER UNITS INSIDE COMM'L APT
I hereby affirm that I am licensed under the provisions of Chapter 9 BLDOS
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 provided for by Sq.I t Floor Area: Valuation:$100
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:32609040.451 Occupancy Type:
APPLICANT CERTIFICATION
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 building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply f
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
LW OWNER-BUILDER DECLARATION RE-ROOFS:
All i oofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of inst:.11ed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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(Sec.7044, Sigi ature of Applicant: Date:
Business&Professions Code) —
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I h:ve read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. con ipliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Sat.-ty Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. ma ntain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall He filth&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Om ne uthopized a ent:� ,V Date: M1 D
become subject to the Worker's Compensation provisions of the Labor Code,I must — X�` ��
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I h,:reby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Le ader's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Le ader's Address
-unify and keep harmless the City of Cupertino against liabilities,judgments,
,,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I uiderstand my plans shall be used as public records.
9.18.
Li:ensed Professional
Signature Date lJ
i
`1 CITY OF CUPERTINO
CUPEf�TFINO GENERAL BUILDING
PERMIT APPLICY�TION FORM
APN# Date:
Building Address:
Mailing Address (if different fr an building ad ress):
ccC-IL
Owner's Name: Phone#:
U e -S
HOA: (Exterior work only) Yes U No ,
If ves, provide letter from HOA
Contractor: Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Ph
Contact: , one: !���, � .2
Fax: SFS- Cl7 3- d
Residential Commercial
Job Description:
Sjc
C o L--4 Nti
P
Building Permit Info: —/
Elect 1, Plunib L� Mech M
Bldg anc Occu Type:
Type of Construction (Usage Class):
Occupancy YP
2-
1-A, 1-B ❑ II/III/V-A ❑
II/III B IV-HT, V-B [v� �—
Valuation: / Square Footage:
/ E�a,
Project Size: Express ❑ Standard R'O"' Large ❑ Major ❑
Green Building: Please complete relevant portion of tLe Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For WE, contact Build it Green at www.builditgreen.or
Revised 02/05/09