09080067 (2) CITY OF CUPERTINO BUILDING PERMIT
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BUILDiNG ADDRESS: 10870 N STELLING RD BLDG 41 A-H CONTRACTOR:WEST BUILDERS,INC. PERMIT NO:09080067
OWNER'S NAME: VILLA SERRA APTS A CA LTD PAR"fN 1608 4TH ST STE 120 DATE ISSUED:08/19/2009
-'ER'S PHONE: 6509313457 BERKELEY,CA 94710 PHONE NO:(510)525.9378
[� LICENSED CONTRACTOR'S DDEE'CCCLARATION E+UILDiNG PERMIT INFO: BLDG ELECT PLUMB
License Class_ __-- Lic.# �=/J 6
MECH RESIDENTIAL COMMERCIAL
Contractor �3 � _Date __
-_--- JOB DESCRIPTION:REViSION UTILITY CLOSET
1 hereby affirm that I am licensed under the provisions of Chapter 9 ORIGINAL 07120135
(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:
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
ESPN Number:32609056.41 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that i have read this application and state that the above intbrmation is
icorrect. I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction.auJ hereby authorize representatives ofthis city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioncc;property for inspection purposes. (We)agree to save
mdenmi!i and keep ha!nilcss the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,vnd expenses which n;ay accrue against said City in consequence of the
I granting of this permit. Additionally,the applicant understands and will comply Z`'(
with all non-point source regulations per the Cupertino Municipal Code,Section issued by: � � Date:
r'zDate
Signature -----___-- —
RE-ROOFS:
L OWNER-113VILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed. If a roof is
nstalled without first obtaining an inspection,I agree to remove all new materials for
i hereby affirm that I ant exempt from the Contractor's License Law for one of nspection.
the following two reasons:
1,as owner of the property,or mv.y 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)
ALL ROOF COVERINGS 1-0 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
i herebv 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. I will maintain
Compensation,as provided Im 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 25.532(x)should I store or handle hazardous material.
Aeditionally,should I use equipment or devices which emit hazardous air
I have and will maintain W akcr's Compensation Insurance,as provided for by contaminants as defined by the Day 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 lvlunicipal Code,Chapter 9.12 anti t re
3 permit is issued. Ifealth&Safety Code,Sections 23505,25533.and 25534.
1 I certify that in the perfonnnnce of the work for which this permit is issued-I shall
not employ any person in any manner so as to become subject to the Worker's Por aut r'zed agent:Compensation laws of('alilbn;ia ll'.,after making this certific:te of exemption,lDate:
become subject to the Work,is Compensation provisions of th:e Labor CoJe,I must
forthwith comply with sw1i provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
!hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION fbi which this permit is issued(Sec.3097,Civ C.)
I certify that I have read:his application and state that the abov,;information is Lender's Name_— —
correct. I agree to comply with all city and county ordinances vnd 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.(We)agree to save
ind•minify and keep harmless the City of Cupertino against liabilities,judgments, ARCH)TECT'S DECLARA7 ION
C *rd expenses which may accrue against said City in consequence of the
gra .rg of this permit.Additionallx,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 — _ — --
Date ----