09030130CITY OF CUPERTINO
DIVISION PERAVIIT�lR�i�'1
IC?IZ1AI�N: _'
BUILDING
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #274
TBD — TO BE DETERMINED
09030130
OWNER'S NAME:
PERMIT ISSUE DATE
2999
PHONE:
S R CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job DOSCrlptl0❑
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force andeffecL
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
License Class Lie. #
Dale Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 703 1.5, 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 far such permit to file 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 Professions Code) or
100
1 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 penally of
not mots [ban five hundred dollars ($500).
32609041 .274
El I, as owner of the property, or my employees with wages as their sole compensation,
RequiredIns Inspections
p
will do the work, and the structure is not intended or offered for sale (Sec. 7044, B usiness
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 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
Sal
owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li.
cense taw does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
01 am exempt under Sea B& P C f r thiss` axon
�/�4����!ION
Owner Y 1 \
I hereby affirm under penalty of perjury one of the following declarations:
M IhaveandwillmaintainaCertificateofConsenttoself-insureforWorker'sCompen-
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
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 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 (S 11x1)
or less.)
I certify that in the performance of the work fo which this permit is issued, I shall not
employ any person in any manners o3s �o bpco sq cls the Workers' Compensation
'lam
Laws of Californj . Date b
Applicant AA
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workees 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
y the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lcndees Address
I certify that I have read this application and state that the above informadun is
" corecL 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
n liabilities, judgments, costs and expenses which may in anyway accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO -POINT
Issued by: Date "
SOURCE REGUATIONS,
x .. DG
-_
Re -roofs
Type of Roof
Signature of ApplicanVContrac or I D ta
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Cede, Section 25532(a)?
No
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
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 as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yesu
1 have mad the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that If the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
re immcnts which be mel pri to issuadN cera Certificate or occupan.
Signature of Applicant Date
It
All roof coverings to be Class or or better
Owner oraulhorircdaa,o
genl