090301182
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CITY OF CUPERTINO
PERMIT
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #252
TBD — TO BE DETERMI
OWNER'S NAME:
PERhffr ISSUE DATE
PHONE
CONTROL NO,
ARCHITECT/ENGiNEMU
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
IoDescr
Description
1 hereby .!Lino that I am licensed under provisions or Chapter 9 (commencing
�)
with Scction 7000) of Dividon 3 of the Business and Professions Code, arid my Be== is
in full force and effect.
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
enseC"' L`'#
Date Contractor
Da
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHI7ECrS DECLARATION
1 understand my plans dull be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following mason. (Section 70313. Business and Professions Code: Any city of county
which requires a permit to construct. alter, 'improve. demolish, or repair any structure
prior to its issuance. also requires the applicant for such permit to rile a signed sudemmt
Ft. Floor Area
Valuation
that he is licensed ptmuam to the provisions of the Contractors License Law (Chapter 9
Sq.
(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 or
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than fire hundred dollar (—%M
32609041 .252
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered forsale (Ser. 7044. Business
and Professions Co&e: The Conmmors I ken Law hoes 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 forsale. If,
however. the building or Improvement is sold within one year of completion, the owner-
buUga will have the burden of proving that he did not build or improve for purpose of
licensed cottracwrs to
Las owner of the property. am exclusively contracting with
construct the pmject (Sec. 7044, Business and Professions code:) The Contra uses Li-
cense Law does not apply to an owner of property who builds or improves thereon. anti.
who contracts forsuch projects with a contractor(s) Ifcmtwd purauant to the Contractors
License Law.
❑ 1 am exempt under Sec. B R P C for
1
Owner Dau
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty or perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Lobar Code, for the performance of the
wort for which this permit is iared.
❑ 1 have and wBl maintain Workers Compensation loan=, as required by Section
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 ac
Cartier. Policy No.:
CEKMCATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(rhis section need not be completed if the permit is for one hundred dollars (S 100)
Of less)
this permit is issued, I shall nes
I certify that in the performance of the we�h�cc
pfatnr ew�ich
employ any person In any manner m shbjfat Workers' Compensation
7 1 b
Laws of Califn ate 7 1 b 11 S1i/ _
Applicant
NOTICE TO APPLICAM: If, after malting this Certificate of Excmpdm you should
become subject to the Workers Compensation provisions of the Labor Code, you mus
forthwith amply with such provisions or this permit shall be deemed mvokcd.
CONSTRUCTION LENDING AGENCY
1 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 Nartm
(.Anders Addrm
1 certify that I have mad this application aid suite that the above information is
correct. 1 agree to comply with all city and county ordlnanegs and state laws relating to
building construction, and hereby authorise represematvea of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to sate, Indemnify and kap harmless the City of Cupertino against
liabititlex,judgmcnts, cosi and expenses which may in any way accnm against sold City
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WrrH All NON- INT
Issued by: Date 5 . Oq
SOURSOURCE^REGULATTO
^
v La y�' S G 04
Re -roofs
Type of Roof
—�
Signature of Appliant/Contracsor Dak
HAZARDOUS MATERIALS DISCLOSURE
Will tin: applicant or future building occupant sore or hassle hassrdous material
as defined by the Cupertino Municipal Code. Chapter 9.11, and the Health and Safety
Code. Section ass32(a)7��
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ono
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or futore building occupant use equipment or devices which
emit ha7srdous air contaminants as defined by the Bay Ara Air Quality Mahngemcm
all new materials for inspection.
District?
+Q(o
0 y
1 haw read the luumdo s m umis' mquimmew under Chapmr 6.95 of tree Califor-
niaHalthRSafciyCod0.Sectau15M5.2S533and]SS34.lundcrsaW"ifte building
does not currently haw a tenant. that It is my responsibility to notify the eceih t of the
mga�tyj� 1p�mrto���� rhateoro
Signature of Applicant Date
,�(/ ^� A A /
All roof coverings to be Class '?Y' or better
Ownerorwthanitdagent etc