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CITY OF CUPERTINO
3TI�'
BUILDING DIVISION PERMIT
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BUI I c,� ESS:
PERMIT NO.
HOMESTEAD RD, BLDG 12A—H
WEST BUILDERS, INC.
08050121
OWNER'S NAME:
PE10M ISSUE DATE
VS II A CALIFORNIA LIMITED
1608 4TH ST STE 120
06/10/2008
PHOnia t? TNT
SANITARY NO. CONTROL NO.
ARCHn ECTIENGiNEER:
BUMDING PERMIT INFO
REVISION—WATER SUPPLY&RETURN BLDG ELEcr PLUMB MECH
0 0 0 0
LICENSED CONTRACT'OR'S DECLARATION
-Job Description
I hereby air= that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and PAf ant! my license is
in full force and effect. [b7 5
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Da ci°rf.2pro
ARCHrfEUrS DECLARATI
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's Ucansc Law for the
following reason. (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 for such permit to Glc asigned statement
Ft. Floor Area
Valuation
that he is licensed pursuant to the pmvisions of the Contractor's license Jaw (Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
not more that five hundred dollars (5500).
❑ L as owner of the property, or my employers 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 Contramor's License Law docs not apply to an owner of
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property who builds or improves thereon, and who doessuch 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 -
builder will have the burden of proving that he did not build or improve for purpose of
mak J.
❑ L as owner of the property. am exclusively contracting with licensed contractors to
cmnsruct the project (Sec 7044, Business and Professions code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thamn, and.
who contracts for such projects with a contractor(s) licensed pursuant to the conumoes
License Law.
[:]I am exempt under Sec , B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificate of consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compenvton 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 Compensationhunuanct: carrier and Policy number arc:
Carrier: STAT 1:yy_*Policy No.: ::764Z
.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section nerd not be completed if the permit Is for one hundred dollars(S 100)
or less.)
I 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 Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you mus
forthwith comply with such provisions or this permit shall be deemed revoked
I CONSTRUC1lON LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
'
Lender's Address
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 concoction, 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,jodgments, costs and expenses which may in any way accrue against said City
iin consequence of the granting of this permit.
APPLICANT_UNDEWANDS AND WILL COMPLY WITH ALL NON-PQ�Nr
Issued by: Date
SOURCE ULATIONS. (/�J
/O. /�
.
Re -roofs
Type of Roof
Signature of Applt o r Date
HAZARWSATERIALS DISCLOSURE
Will applicant orfiftyVe bat ding occupant sore or handle hrmrdous material
as defined byCope M ci ' al Code. Chapter 9.1 7, and the Health and Safety
Code•seeti°" ;"
❑Yes IGtvo
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
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 o
I have read the hazardous materials requirements; under Chapter 6.95 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
requlmments which et prior to Occupancy.
Signature of Applicant Date
All roof coverings to be Class'n" or better
Owner
or authorized agent Data
IL
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CUPEkTINO
CITY OF CUPERTINO
REVISION/DEFERRED
PERMIT APPLICATION FORM
0�0-�50I,�,) I
APN # Am� O q05�- ra i 1
Date: 6.
Original Permit #: ,6Zbk /ZA _ D p'OW;?30
Z,0 . 36A-Halpd8'D 1
Building Address::'
aL X34 -A-3 #0864022 5"
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f,08epe2 �i0/l'1�E,415�_
o Z 34 -
Mailing Address (if different from building address):
$LDC , (03 Ft 1W,040Z 261
Owner's Name:
Phone #:
9 3
Contractor:
Phone: 510 - 52 S- g
V,JG 67
Fax: ":9 10 - !:—:>I-
2 - q
Contractor
Contractor License #: gZ 15 3c 5
Cupertino Business License #:
Contact:
Phone:
Fax: 40-141(,o— 50 3
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
E�/ Mech ❑
Residential LZ Commercial
Job Description:
h is I�IA��� S'v j�PG A�V
D /2,15721 1AI Pl�p f D elp'll
Is the project in the Wildland- Urban Interface Fire Area? Yes ❑ No LK
Type of Construction (Usage Class):
* Occupancy Type:
1-A, 11-B ❑ 11,111,V -AE] 11, 111, IV V -B
2 — (
Project Size: Standard Large Major
Valuation (cost of project):
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include
in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.buildit een.or
CITY OF
CUPERTINO
CITY OF CUPERTINO
REVISION/DEFERRED
PERMIT APPLICATION FORM
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
1REVCOMNEW
Revision Commercial New
B
1*
1REVCOMTI
Revision Tenant Improvement
B
1* TI
1REVSFDWL
Revision SFDWL
B
1R3SFDW
1REVRESADD
Revision Addition
B
1R3SFDADD
1REVRESREM
Revision Remodel
B
1R3SFDREM
1 DEFINSP
Deferred Submittal not R-3
Inspection
B
1
1DEFPLNCK
Deferred Submittal not R-3 Plan
Check
B
1* OR
1* TI
1DEFR3PLNCK
Deferred submittal R-3 Plan Chk
B
1R3SFDW
1R3SFDADD
1R3SFDREM
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