09030128CITY OF CUPERTINO
PERMIT
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BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #270
TBD - TO BE DETERMINED
09030128
OWNER'S NAME:
PERMIT ISSUE DATE
2009
PHONE:
S AR CONTROL NO.
ARCHiTECl7ENGINEER:
BUILDING PERMITINFO
BLDG ELS PLUMB ME�CHI
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
infull orcea doffecDivision3aftheBusinessandProfcssionsCodo,andmyliccnscis
in full force and ofrecL
License o
Dnti actor
Dam Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITEC'SDECLARATION
COMMENTS.
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the 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
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to Ole a signed statement
License Law 9
that he is licensed pursuant to the provisions of the Contractor's (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
10 0
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 mem than five hundred dollars ($500).
32609041 .270
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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will do the work, and the structure is not intended or offered for sale (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
awn 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.
build will have the burden or 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 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 Contractors
License Law.
❑ 1 am exempt under Sec. , B & P C or tii" reason
.
Owner 1� /ICLA 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-insum Cor 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 Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the permit is for one hundred dollars ($100)
nr less.)
I certify that in the performance of the wit for vhich Otis permit is issued, I shall not
employ any person in any manner so tm c am so ct a haworkers, compensation
Laws of Califarq"a. Da `
Applicant
NOTICE TO APPOCANr: If, after making this 'crtificatc 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 aflirm that there is a construction lending agency for the performance of
y 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. 1 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
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
y
1 liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date 5. U - 0
S URGE REGUL TIONS.
—
Re -roofs
Type of Roof
XiM..n�. 'i A bw
Sig aturc of Applicant/Contractar Date
HAZARDOUS MATERIALS DISCLOSURE
Will 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 25532(a)?
r] Yes L�ro
All roofs shall be inspected prior to any roofing material being installed.
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
emit hazardous air contaminants az defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 75534. I understand that irthe building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
uiremcnts Iii must must be t pri to issuance ora Certificate of Occupancy.
I('
Signature of Applicant Date
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All roof coverings to be Class 'A" or better
'
Owner or aulhorixcd agent rte