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CITE' OF CUPERTINO
DIVISION PERMIT
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BUILDING
BUILDING ADDRESS:
PERMIT NO.
20990 VALLEY GREEN DR #606
TBD — TO BE DEMERMINET-)
09030089
OWNER'S NAME:
PGUNPATION
PERMIT ISSUE DATE
PHONE:
S CONTROL NO.
ARCHITECUENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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 ClassLie. #
Dale Contractor
E/M/P' S—SEE PERMIT 1109030198 FOR PLAN CK
ARCHITECT'S DECLARATION
1 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 reason. (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 far such permit to file a signed statement
License Law 9
Sq. Ft. Floor Area
Valuation
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
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
not more than rive hundred dollars ($500).
32609053 .606
❑ 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 oroRered forsale. 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
sale.
LV I. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Conuacrmrs Li.
cease Law does not apply to an owner of property who builds or improves themon, and •
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P CCf r this reason
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Owner y M/t, n� Data
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 -insure for Workers 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 Workers 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 number are:
Caries Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (5100)
or less.)
I certify that in the performance of the work for 4ich this permit is issued, 1 shall not
employ any person in any manner so 13 6cC;c s bjettJ IgWorkers' Compcnsa6on
Laws of Californiii.�IL�Applicant
\ % - —
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name —
Lenders Address
j 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 canswcdon, 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
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N.P NT
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Issued by: Date I � _(! , U —(
SOUn R�ULA CA �
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Re -roofs _
Type of Roof
Signature of ApplicanVContraclor bate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle hazardous material
as defined by the Cupertino Munici 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 o
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 two
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand thtu if the building
does not currently have a tenant, that it is my responsibility to notify the occupan of the
requirements oldch m1 ust be met priI Lo suartce of��'ficate of Oc5 e�
Signature of Applicant Date
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All roof coverings to be Class','`' or better
Owner or authorized agent