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090130134IU i<a z iFµ 1LC low I u jqG �^u .z� 3s� y CITY OF CUPERTINO PERMIT���• BUILDING DIVISION BUILDING ADDRESS: PERMIT NO. 20800 VALLEY GREEN DR #501 TBD — TO BE DETERMINED OWNER'S NAME: PERMIT ISSUE DATE PHONE: S A CONTROL NO. ARCHITECT(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing 7000) INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES infullforcnndeffecDivision3ofthoBusincssandProfrssiunsCode,andmylicenseis in full force and effect. License Class Conti Date Contractor Date E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK ARCHTTECI'SDECLARATION COMMENTS. I understand my plans shall be used as public records ( DOUBLE FEES) Licensed Professional OWNER -BUILDER DECLARATION 1 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 rile a signed statement law 9 that he is licensed pursuant to the provisions of the Contractors License (Chapter (commencing with Section 7000) of Division 3 of the Business and Profossions Cedc) or 100 I 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 penalty of net more than rive hundred dollars ($500). 32609040 .501 [11, as owner of the property, or my employees with wages as their sole compensation, Required Inspections q P will do the work, and the structure is not intended or offered forsale (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 oroRered forsale. 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 sale . I, 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 docs not apply to an owner of property who builds or improves themon, and, who contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under nSea B & P C fo this mason ,n Owner)M Yti.rr _ / liyl/l�Date WORKER'S COMPENSATION DECLARATION , I hereby affirm under penalty of perjury one of the following declarations: ❑ I 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. ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workees Compensation Insurance carrier and Policy number am: Cartier. Policy No,: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the w9rk for hich this permit is issued, I shall not employ any person in any manner so �bccom uhiccbto the Workers' Compensation Wit Laws of California. Die , �/ I 1 Applicant — ASA NOTICE TO APPLICANT: If, after makingthls 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 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.) Lender's Name Lender's Address 1 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 upon the U above-mentioned property for inspection purposes. L( (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, in way accrue against said City rj judgments, costs and expenses which may any 7 in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE REGULATIONS. S W1 ,. L„ ._� U9 Re -roofs _ Type of Roof r Signature of Applicant/Contractor Dad HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupantstore orhandle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed, ❑Yes LyNo 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 MR hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? / &We ❑ Yes 1 have read the hazardous materials requirements under Chapier6.95 of the Califor- nia Health &SafctyCodc, Sections 25505,25533 and 25534.1understand thatifthe building does not currently have a tenant, that It is my responsibility to notify the occupant of the re uiremen1 whi must b • met poor to issuance of a Certificate of Occaney. Signature of Applicant Date 51-7y" �� All roof coverings to be Class "`` or better Owner or authorized agent Dae '