09080037 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 20800 HOMESTEAD RD BLDG 5 A-H CONTRACTOR:WEST BUILDERS,INC. PERMIT NO:09080037
OWNER'S NAME: VILLA SERRA APTS A CA LTD PARTN 1608 4TH ST STE 120 DATE ISSUED:08/19/2009
0"':NF,R'S PHONE: 6509313457 BERKELEY,CA 94710 PHONE NO:(510)525-9378
Q LICENSED CONTRACTOR'S DECLARATION
,e�.�� BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class L _ Lic.# a y��>
�� � .Z� MECH(— RESIDENTIAL [— COMMERCIAL �
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REV IS ION: UTILITY CLOSET
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq,Ft Floor Area: Valuation:$2500
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. .CPN Number:32609056.5AH Occupancy Type:
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: .f Date:• Z-`i 'ds
9.18.
Signature _ __ Date 6*Z7Y
RE-ROOFS:
C OWNER-BUILDER DECLARATION /.II roofs shall be inspected prior to any roofing material being installed. If a roof is
i istalled without first obtaining an inspection,1 agree to remove all new materials for
I hereby affirm that 1 ant exempt from the Contractor's License Law for one of i rspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business do Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code). —
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's (alifornia Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the c)mpliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the"ork for which this c rntaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued.
n aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 1 certifythat in the performance of the work for which this pen;rit is issued,1 shall H ealth&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's C r autho ed agent:
Compensation laws of California. If,after making this certificate of exemption,1 _ -Date: if.ZY.
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked. w CON'ST'RUCTION LENDING AGENCY
I tereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION fcr which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is L:nder's Name___ _
correct.1 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 L-nder's Address__
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
a nd expenses which may accrue against said City in consequence of the
gh, .g of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
t 9.18. L censed Professional
Signature ___Date____