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09030144CITY OF CUPERTINO BUILDING DIVISION PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR #291 TBD — TO BE D OWNER'S NAME: PHONE: ARCHITECTIENGINEER: o o LICENSED CONTRACTOR'S DECLARATION W p I hereby affirm that I am licensed under provisions of Chapter 9 (commencing U w with Section 7000) of Division 3 of the Business and Professions Code, and my license is a y in full farce and effect. License Class Lic. k E Date Contractor �1 ARCHITECTS DECLARATION i < I understand my plans shall be used as public records i0.U W y Licensed Professional i y OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the inc 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 y y�' prior to its issuance, also requires the applicant for such permit to file a signed statement x C that he is licensed pursuant io the previsions of the Contractor's License Law (Chapter 9 F (commencing with Section 7000) of Division 3 of the Business and Professions Code) or `i that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of pre than rive hundred dollars (5500). as owner of the property, or my employees with wages as their sole compensation, 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 or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - build r will have the burden of proving that he did not build or improve for purpose of sal , 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 thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 am xemp�t under nSea n , B & P C fo Ihi anon Owner ��lr I.ArL-�'L i�./�..�� Date WORKER'S COMPENSATTON 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. ❑ 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 Worker's Compensation Insurance carrier and Policy number am: Carrier. 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.) I certify that in the performance of the rk fo which this permit Is issued, I shall not employ any person in any manner so t• brrh c s b' ot he Workers' Com enaton Laws of California. Dae Applicant V.Aa - - ^— NOTICE TO APPLICANT: If, after making this C nificatc of Exemption, you s .Id become subject to the Workers Compensation provisions of the Labor Code, you must O forthwith comply with such provisions or this permit shall be deemed revoked. Cn CONSTRUCTION LENDING AGENCY 1 hereby affirm that them is a construction lending agency for the performance of 1!' the work for which this permit is issued (Sec. 3097, Civ. C.) ALenders Namc Z Lenders Address J 0 I certify that I have read this application and state that the above information is .4 � correct. I agree to comply with all city and county onifnances and state laws relating to 3U 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 rA liabilities,judgmenls, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. i- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT sow REGULATION . Signature of Applicant/Conuaclor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hayardous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes In No 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 District? ❑Yes o Job Description INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK COMMENTS. Ft. Floor Area 100 32609041.291 Required Inspections Issued by; Re -roofs Type of Roof Valuation Occupancy Date `Cj - Le 109 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 all new materials for inspection. I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Section 25505, 25533 and 25534. I understand thatif the building does not currently have a tenant, that it is my responsibility to notify the occupant of the re uirements whiq� nmr must be m issuance of a Certificate of Oce pant Signature of Applicant Date Vim. -OA-A ,t a I L5C( All roof coverings to be Class 'A"' or better Owner or authorized agent D le ' PERMIT NO. D 09030144 PERMIT ISSUE DATE S AR CONTROL NO, BUILDING PERMIT INFO BLDG ELECT PLUMB 0 Job Description INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK COMMENTS. Ft. Floor Area 100 32609041.291 Required Inspections Issued by; Re -roofs Type of Roof Valuation Occupancy Date `Cj - Le 109 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 all new materials for inspection. I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Section 25505, 25533 and 25534. I understand thatif the building does not currently have a tenant, that it is my responsibility to notify the occupant of the re uirements whiq� nmr must be m issuance of a Certificate of Oce pant Signature of Applicant Date Vim. -OA-A ,t a I L5C( All roof coverings to be Class 'A"' or better Owner or authorized agent D le '