09030096CITY OF CUPERTINOs
r y
BUILDING DIVISION PERNUT
BUILDING ADDRFSS:
PERMIT' NO.
20975 VALLEY GREEN DR #221
TBD - TO BE DETERMINED
OWNER'S NAME:
PER64ITISSUE DATE
PHONE:
S CONTROL NO,
ARCHPIEC IENGINEER:
BUfiLDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 a a
LICENSED CONYfRACTOWS DECLARATION
Job Description
I hereby affirm Ow I am licensed under provisions of Chapter 9 (commencing
p
with Section 7000) of Division 3 of the Business and Professions Code. and my license is _
-
infuliforeeandefect
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
Dam cl,:: co
acontractor
E/M/P' S -SEE PERMIT #09030198 FOR PLAN CK
ARCHrmcm DECLARATION
I understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER-BUMDP.R DECLARATION
1 hereby affirm that I am exempt from the Conuaetors License Law for the
following reason (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, miter, improve, demolish, or repair any structure
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
(commencing with Section 700D) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and he basil for the alleged exemption. Any violation of
$200
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy
P cy Type
not more than five hundred dollars (S500)
32609041.221
❑ L as owner of the property, or my employats with wages as their sole compensation,
Required Inspections
will do the work tad the structure is not intended or offered for ask (See. 7044. Business
and professions coda: The Centracmrs License Law does not apply to an owner of
property who builds or hnproves tbercon and who does such work himself or Ltt mgh 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
oak.
L as owner of the am exclusively contracting with licensed contractors to
property,
consents the project (Sec 7044. Business and Professions Code:) The Contractors Ir
ansa Law does 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.
❑ 1 am exempt under Sec , B R P C far reason
Date
WORKER'S COMPENSA31ON DECIARAMON
I hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a CmUnose of Consent to self -Insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the perform&= of he
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Scetimn
3700 of the labor Code• for the performance of the wort for which this permit is Issued.
'
My Workers Compensation Insurance carrier and Policy number ase:
Cartier. Policy No.:
CER771F1CATE OF EXEMP 7ON FROM WORKERS'
COMPENSATION INSURANCE
(itis section need not be completed if the permit is for one hundred douse (S 100)
or lets)
I certify that In the performanof a work for which tes
ce his permit is issued. l "I n
employ any person in any mann u b co s 'eel to the Workers' Compensation
Laws of California. Date r
Applicant
NOTICE TO APPLICANT: if, after making this Certificate Sf Exemption, you should
become subject to the Workers Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this peanit shall be dexmcd rmkcd.
CONS TRUC ION 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. Q
Lenders Name
Lenders Address
1 certify that 1 have mad this application and sate that, the above information is
'
correct I agree to comply with all city and county ordinances and stare laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purpose.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
/17
liabilities, judgments, toss and expenses which may in any way scene against said City
APLIC consequence of the granting Sthis permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date U
S0� ILECaULATfONS .
—
Re -roofs
Type of Roof
Si of AppifcantfContrector r—rD�9
HAZARDOUS MATERIALS DISCLOSURE
Win 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 2ss3ua)7
All roofs shall be inspected to any roofing material being installed.
l�m
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or rotor building occupant use equipment or devices which
emit harudous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
DLtuitt7
0 Ya DUN/
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &SafctyCode, Sariau 25505.25533 and 25534. l understand that if the building
dna riot currently have a team• that It is my responsibility to notify e nccvpan of do
the
wicks i>e met
rcqui,emcn re m mr a �er;rneate or
Signature of Applicant Date
All roof coverings to be Class' ' or better
g
Owner '
or authorized agent Date