09030139%i
CITY OF CUPERTINO
DIVISION PERMIT
BUILDING
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #279
TBD — TO BE DETERMINED
OWNER'S NAME:
PERMIT LSSUE DATE
8 8 9
PHONE:
S CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMrrINFO
BLDG ELECT PLUMB MECH
0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
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 and effect
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
License ClassLic. #
Date Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHrrEC'S DECLARATION
1 understand my plans shall be used as public records
COMMENTS.
Licensed Professional
OWNER -BUILDER DECLARATION
I 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
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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
net mem than live hundred dollars ($500).
32609041 .279
❑ 1, 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 for sale (Sec. 7044, Business
and Professions Code: The Conuactues License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or lhmugh his
own employees, provided that such improvements are not intended or offered for We. If,
however, the building or improvement is sold within one year of completion, the owner-
will have the burden of proving that he did not build or improve for purpose of
owner of the property, am exclusively contracting with licensed contractors to
instma
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 contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sea B & P C or this reason
b b
Owner ate
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 forWorkees 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 Workees 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 forone hundred dollars ($100)
or less.)
I certify that in the performance of the it Cor which this permit is issued, I shall not
employ any person in any manrm�r !4 bkcofp lecl to the Workers' Compensation
�'t
Laws of California. D .3 ` V
Applicant
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 there is a constructinn 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 1 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
ahove-mentioned property for inspection purposes.
(We) 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
6
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO -POINT
Issued by: Date
SOURCE REGULA� IONS. p `
`1M
_.
, ,e, _X �'` /U�s S 6 b ql
Re -roofs
-"'
Type of Roof
Signature of-Applicant/Contractor Ditto
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 Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑ No
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?
❑ Yes ❑ No
1 have read the hazardous 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
rents which rgust be mel rior la • dance ora Cerufmcate of oeeugmcy
Signature of Applicant Date
S I b�
]� m i ►�^" 16
All roof coverings to be Class'" or better
Daly
-
Owner or authorized agent