09080061 CITY OF CUPERTINO BUILDING PERMIT
IPERMBUILDING ADDRESS: 20800 HOMESTEAD RD BLDG 34A-B CONTRACTOR:WEST BUILDERS,INC. DATE I NO:09080061
OWNER'S NA,%]E: VILLA SERRA APTS A CA LTD PARTN
if 08 4TI1 ST STE 120 A"fSSUED:08/19/2009
(V-'NER'S PHONE: 6509313457
B EERKELEY,CA 94710 PHONE NO:(510)525-9378
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r
License Class Lrc.4 RZ53q-5 MECII f— RESIDENTIAL r COMMERCIAL
Contractor WX Date 6',2y'
JOB DESCRIPTION:REV ISION-UTILITY CLOSET
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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 Valuation:$2500
performance of the work for which this permit is issued. ''q.Ft Floor Area:
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 APN Number:32609056.34AB Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
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 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 CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the S
granting of this permit. Additionally,the applicant understandpand will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature _ _Date 4-
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
OWNER-BUILDER DECLARATION
( installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection,
the following two reasons: Date:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant:
will do the work,and the sty ucture is not intended or offered for sale(Sec.7044, --
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
1 hereby affirm tinder penalty of perjury one of the following three
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
nt to self-insure for Worker'sCalifornia
I have and will maintain a Certificate of Consecompliance Health
the CupertinodMunicipal Code,Chapter 9.12 and the Heale,Sections 25505,25533,and 255 . 1 will th&tarn
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material.
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Cod,Chapter 9.12 and the
permit is issued. health&Safety Code,Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,I shall s
not employ any person in any manner so as to become subject to the Worker's �)wopau�tthlhorizled a$tnt: Date:�-C7'Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUC"PION I ENDINC'AGF,NCY
forthwith comply with such provisions or this permit shall be deemed revoked. '
1 hereby affirm that there is a construction lending agency for the performance of vv ork's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is
Lender's Name
correct. I agree to comply with all city and county ordinances and state laws relatinf Lender's Address
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, ARCHITECT'S DECLARATION
C, nd expenses which may accrue against said City in consequence of the
gr'- ,,g of this permit.Additionally,the applicant understands and will comply 1 understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional_
9.18.
Signature —
Date