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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #266
TBD — TO BE DETERMINED-
OWNER'S NAME:
XORET
PERMIT ISSUE DATE
17
PHONE:
S A CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 a 0
LICENSED CONTRACT'OR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) orDivision 3 of the Business and Professions Code, and my license is
in full force andeffecr.
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
License ClassLic. S
Date Contractor
'
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHrrEcrS DECLARATION
I understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from tho Contractor's License Law for the
following mason. (Section 7031,5, Business and Professions Code: Any city or 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 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 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 of
APN Number
Occupancy Type
l) y tip
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
32609041.266
❑ p perty, or my employees with wages az their salt compensation,
I,asownerofthe property,
Required Inspections
will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs 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 orofrered for sale. If,
however, the building or improvement is sold within one year of completion, the owner-
builde -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
nstto the project (Sec. 7044, Business and Professions Code:) This Contractors 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.
❑ I a exempt u der Sec , B& PC Trihii reason
Owner
WORKER'S COMPENSATION DECLARATION
1 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.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3710 of the Labor Code, for the performance of the work for which this permit is issued,
'
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($1011)
or less.)
I certify that in the performance of the work fi4 hich this permit is issued, 1 shall not
employ any person in any manner so suhiecFiotheWorkers'Compensadon
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Laws or Californi^a. �tis-� '7 r'0 1 17`-'l
^D
Applicant V Y �6G d«�
NOTICE TO APPLICANT: If, after making this 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.
CONSTRUCTION LENDING AGENCY
I hereby affirm that then: 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
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 slate laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(Wo) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence or the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NQN-POINT
` `
Issued by: Date /vl
SOURCE REGUL TIONS.
Re -roofs
Type of Roof
b"(
Si alum of Applicant/Contractor x Da
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hayardous material
az 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.
E] Yes ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or rutum building occupant use equipment or devices which
emit hazardous air contaminants az defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes ❑ No
I have mad the hamnlous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
I.C.tri tents wh. ust be m prion issuanccof a Ccrtiricate or Oce ancy.
(
Signature of Applicant Date
� r 1 L = - 51 6 1
All roof coverings to be Class 'A" or better
Owner or authorixcd agent Dalte