09020109CITY F CUPERTINQ
PERNUT
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BUILDING DIVISION
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BUILDING ADDRESS:
PERMIT NO.
20630 VALLEY REEK 2R
CON 30LIDATED PLUMBING T Nf__
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OWNER'S NAME:
RAD -Avrn
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PERMIT ISSUE DATE
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PHONE:
CONTROL NO.
(408)978-3093
ARCHMCr/ENGINEM.
BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby aflirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Cc&, and my license is
in full form and cfli*4 tin,
'&E�—PIANITRY
REPAIR/REPLC SEWR LINE FM INSIDE BLDG TO EXTNG 6
License Lie. #
CONN @PROP LINE AS PER PLANS SUBMITTD
*TEMP PERMIT *09030033
�Cla;s—
Datecon,aacier-12�
ARCHITECTS DECLARATION
I understand my plans shalt be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from t . he Contractor's License Law for the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires I 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
Contractoes License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(commencing with Section 7000) of Division 3 of the Business and ProfessionsCade) a'
$85000
that he is exempt therefrom and the basis for the alleged exemption -Any viial of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
32610054.01
0 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 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. It,
however, the building or improvement is sold within one year of completion, the owner -
builder wilt have the burden of proving that he did not build or improve for purpose of
sale.).
0 1, 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 contramor(s) licensed pursuant to the Contractires
License Law.
0 1 am exempt under Sec B & P C for WS mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1771 1 have and will maintain a Certificate of Consent to self-insum for Workers Campos-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
CK 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 Workers Compensation insurance carrier and Policy
Policy No.: olIer
LA&- 6
Carrier. -Mo —3—
C�E"RTMCATE RpEXEMPITON 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 work for which this permit is Wood, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
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 affrat that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, CIv. C.)
Leaders Name
Lcndees 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 state laws misting 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
liabilities, judgments, costs and expenses which may in any way accrue against said City
this
in cc f the granting o h s pe
cc IDERSETI c! ' is
M
?AN
4 AND I COMPLY WITH ALL NON -POINT
AP' U AiN
Issued by: Date
SO1 REGUI,6MON tA
Re -roofs
Type of Roof
Signature ofAppli actor Date DOUS MATER
IALS DISCLOSURE
Will:7-21o5nfulturc building occupant store or handle hazardous material
can
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 MINo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment at devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
oy"
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Saletycodc, Sacd Z5505.25533 andZ5534. I understand that if the building
*;:
a ten 4 that is my responsibility to nodry the occupant of the
does t currently have a
.
rcq trends tyldch oinut at ri to issuance of a Certificate or occupancy.
gnature [Applicant Date
All roof coverings to be Class or better
Date
Ownerrorauttho'd adage t