08050189CITY OF CUPERTINO
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BUILDING DIVISION PERNIIT
BUILDING ADDRESS:
10870 N STELLING RD BLDG 22
WEST BUILDERS, INC.
PERMIT NO.
08050189
OW
PERMIT L95UE DATE
PROMETHEUS
1608 4TH ST STE 120
07/09/2008
PHONE:
SANrrARY NO. CONTROL NO.
(510) 525-9378
ARCH=(ENGINEER:
BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with5ecdon 7000)ofDivision 3ofthe Business and ProfessimCode, and mylicense is
INSTALLATION OF EXTERIOR TEMPORARY PROPANE TANKS
in fun force and effect 17
License Cass Lk:. g y77 n
& .
Date Contractor [!/ S
`
y CHITECI'SDECLARATION
TEMPORARY UNDERGROUND PIPES.
1 urdm%=d my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 70315, Business and Professions Code: Any city or county
which requires a Permit to construm alter. Improve, demolish, lir repair any structure
prior to its iauance, also requires the applicant for such permit to file a signed statement
that be is licensed pursoanL to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor AreaValuation
with Section 7000) of Division 3 of the Business and Profusions Code) or
(commencingesfu
$4000
4 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Occupancy TYP e
Section 70315 by any applicant for a permh subjects the applicant to a civil penalty of
not mere than five hundred dollars (s500]i.
3 2 6 0 9 0 5 6 .qj$Nn�g
❑ L as owner of the property. or my employees with wages as their sole compensnion,
Required Inspections
will do the work- and the structure is not intended or offered for sac (Sri 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
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property who builds or improves thereon, and who does such wort himself or through his
two employes, provided that such improvements are not intended or offered for sale. IL
however. the building or improvement is sold widen one year of completion, the owner -
builder will have the burden of proving that he cid not build or improve for purpose of
.
j] L as owner of the property, am =elusively conhaaing with licensed conramns to
construct the project (Sec 704, Business and Professions Code:) The Contractor's U.
cease Law does sot apply to an owner of property who builds or improves thereon, and .
who contracts for such projects with a conuactor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I hs.e and will maintain a certificate of Consent to self -insure for Workm's Compen-
sation. as provided for by Sermon 3700 of the Labor Code, for the performance of the
wort for which this permit is issued
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued.
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My Worker's Compensation Insmance carrier and Policy number am:
Carrier. 7111 F(11* 0 Polity No.: �S
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars (S 100)
or lar)
I certify that in the performance 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 WorkersCompensadon
Laws of California. Due
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
.
forthwith comply with such provisions or this permit shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the wtut for which this permit is issued (Sec 3097, Cry. C)
L.ender's Name
'
Lender's Address
I certify that I have read this application and state that the above information is
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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 bispection purposes
(We) agree to save, indemnify and keep harmless the tarty of Cupertino against
Liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of (L
APPLICANT UNDERSTAND A D ILL CY ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type Of Roof
_
Signature of Applicanucontraetor Due
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
ceae,Section 2ss32(a)?
❑Yes
All roofs shall be inspected prior to any roofing material being installed.
,.�`�.No
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 A6No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & SafctyCodc. Sections 25545.25533 and 25534.1 understand that if elite building
.
dos not torten m notify theoccupant of titer
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