09030122C
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CITY OF CUPERTINO �T
PERMIT
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20975 VALLEY GREEN DR #255
TBD — TO BE DETERMINED
09030122
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
S41ftARY1 NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
70b Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
withSection
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
infull force and
License Class Lic.tl
Dale Contractor
E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
ARCHITECTS DECLARATION
COMMENTS.
I understand my plans shall be used as public records
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 Cor such permit to file a signed statement
License Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the previsions of the Contractors (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Cadc) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
100
APN Number
Occupancy Type
Section 7031.5 by any applicant for a peril subjects the applicant to a civil penalty of
net more than live hundred dollars (s500).
32609041.255
❑ I, 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 Conuactoes License Law does not apply to an owner of
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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 -
buil r will have the burden of proving that he did not build or improve for purpose of
sal ..
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 contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C f r this mason
Owner A �X� � ^ Date
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 peril 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 are:
Carrier.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 o� ►rk�or�w4hich this permit is issued, l shall not
'
employ any person in any manner alit bcc m cl Lathe Workers' Campensaton
Laws of Califomi arc U
Applicant YNA LL:v— A
NOTICE TO APPLICA: If, atter making this Ccrtiricatc of Exemption, you should
NT
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.
t CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lendees Address
j 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 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
j 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 -POINT
Issued by: Date ,
SOuRCEREGULA IONS. 1
Re -roofs
Type of Roof
I/VI ,--t� , /� C\.,� 5 ESI 6�
Signa ur of-Applicant/Contractor DItte
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)9
Yes �o
All roofs shall be inspected prior to any roofing material being installed.
Cl
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 �jNo
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
rcu me is which ust be me nor to is once of a Certificate of Occu ey
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Signature of Applicant Date
l c�I) S b
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- All roof coverings to be Class"... ' or better
Da
Owner or authorized agent