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09080040 F- CITY OF CUPERTIN O BUILDING PERMIT BUILDING ADDRESS: 20800 HOMESTEAD RD BLDG 8 A-H CONTRACTOR:WEST BUILDERS,INC. PERMIT NO:09080040 OWNER'S NAME: ViLLA SERRA APTS A CA LTD PARTN X608 4TTI ST STE 120 DATE ISSUED:08/19/2009 0`11ER'S PHONE: 6509313457 3ERKELEY,CA 94710 PHONE NO:(510)525-9378 C LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT f PLUMB r License Class 4f_ Lic.# 3�_s 4 MECH r RESIDENTIAL I— COMMERCIAL� Contractor� Date ��"�' JOB DESCRIPTION:REVISION: UTILITY CLOSET I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Sectiop 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 AFN Number:32609056.8AH Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is i 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CAL,L,ED INSPECTION. costs,and expenses which may accrue against said City in consequence of the 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: Date: 9.18. Signatu Date-9 2 Y. RE-ROOFS: OWNER-BUILDER DECLARATION 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 i hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection. 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&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER ER construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three declarations: i 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 California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance 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 I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. health&Safety Code,Sections 25505,25533,and 25534. 1 1 certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Worker's Oor author's Compensation laws of California. If,after making this certificate of exemption,1 ___ __Date: become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY i hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) 1 certify that 1 have read this application and state that the above information is Lender'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 Lender's Address__ upon the above mentioned property for inspection purposes.(a'l'e)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION ct nd expenses which may accrue against said City in consequence of the gra 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 9.18. Licensed Professional Signature ___ Date