07120172 CITY OF CUPERTINO
BUILDING DIVISIONPERNIIT nCONI C111OR :
BUILDING ADDRESS: PERMIT NO.
20800 HOMESTEAD RD, BLDG 20A-H TBD - TO BE DETERMINED 07120172
wNER'S NAME: PERMIT ISSUE DATE
VS 11 A CALIFORNIA LIMITED 07/14/2008
pNa"P,I,Nl SANITARY NO. CONTROL NO.
ARCHRECT/EIGINEFR: BUILDING PERMIT INFO
REMODEL-NEW DECK RAILS, BLDG ELECT PLUMB MISCH
:00 LICENSED CONTRACTOR'S DECLARATION JOb escri tion
r� 1 hereby aflutter Mail 1 am Ikcnced under provision of Chap.9(mmmenctnj .._.------ ..__^^^ p
with Section]IXIU)of Division J of the Businav and Pmleadmn Comae,and my license is
s in full farce end cffett 25
j z Lice CI Lk.I
c— Dao: Cmamomf
I
aml IT DECLARATION
t in< 1nd
uernmy plans"I be used as Public records
Dyu
gG Liccnud Profmommal
OWNER-BUILDER DECLARATION
s�<i I hereby alarm that 1 em eacrept from the Contractors License Law for Ne
00 following reason(Sccuon 70711,Business and PmfeuVans Conk:Any city or county
El M which requires a permit m consumer.elect.improve,demolish m repair any Jmmum
prior to iu issuance.alum require the apidinm far such permit W Bk a sigr¢d moment
ent
pp < InuheiauceamdpurmwnwmepmaJonsofMan Contractors uanneLaw(Chapter 9 Sq.Ft. Floor Area Valuation
Y $ (commencing with Section 7000)of Division]oflW Busines and Profcraions Code)or
Nat lm u bade, thecefeam and IK baso fat the Winged eawptim.MY violation of
Section]ons by am applicans for a Permit subjects Me applicant W a civil penalty of APN Number Occupancy e
No mart Wan five hundred dpllus(5300). P Y TYP
❑1,as owner of the prof".M my employes with wags as Weir WIC compewia",
will do the work,and Meso name,ts not ineended or offered for and:(Sec.]ON,Bummus
w Professions Code:The Comexwrs Liec.law dm nal apply W an ow.of Required Inspections
pmpeny,who Wildeorimproves thrtcon,and who doessuchavrkhimaelforthrough hie
own employers,provided Madmen improvements are not intended reoffered image.B.
however.Me Wilding or improvement is cold within one year of completion,the owner-
builder will have the WNen of proving that he did net Wild or improve for purpose of
sale J.
1,ss owner of the property am exclusively canoed.;with licem red conuxtms W
Wnslmin Me pojem(Sec.]Dna,Business and Profesuam Cade:)Then Coavaetors U. .
cents Taw does cot npplr to an owner of property,who Wilds or improve thereon.and
who contracts forsuch projects witha wnvxtor(a)Ilcurxd poisoned to Me Continuum,
Licam"raw.
❑I M exempt under Sec. .B&P C for thb reawn
w v Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm muter penalty of perjury oro of de,following dedi enti on,
I have and will malnuia•Cerufma a ofComem W self-imum far Workers Campce.
cion,as provided for by Sema.7.100 of the labor Code.for the performanme of the
wart for which Mia permit is issued.
❑1 have and will momma Workers Compensation I..as required by Section
3700.f Me labor Code,for Me performance of Me wort for which thin perrok ire issued. '
My Waster Cam lom�fe�an¢curie end Policy�n'Ju(m�Lber aom:((yyn
Carrier. � r�Policy No.: �l Vl
CERTIFlCATE OF MEMPrION FROM WORKERS
COMPENSATION INSURANCE
(thin amen need trot W completed If We permit u two.tendered do0ae film]
or less)
I wary Met in Mm perfumemec of the work rot which this Pernik is Tarred.I"I am
employ any person in any manner an u W become subject to the Worl¢n'Compmuation
laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject in the WOrtcr!Compertaidon pmvisam of the Labor Codc,you a=
.,O forthwith comply with such provi2ons or Mu permit Dull W deemed mated.
'Z"' CONSTRUCTION LENDING AGENCY
[-�4 I hereby affirm wt Wert is.com nrIbut lending agency for the ne fumoroa of
6i > Me work for which this permit Inc owed(Sec.Jm],Cir.C.)
06 Q Lenders Name .
;:I
z lenders Address
V O I cmay that I have read th a application and mW Mar dec above laureation is
L+ coram.l agree W comply with JI city and county oNinances and sun laws relating W
.O Wilding construction.and hereby,mmouve repmucnuuves of Mts City W enter upon the /��! �,/try(/�, /
D.1 ahove-manupmpcny forinspection which a �/—_�/ �
"y (We)agree to save,indemnify and keep harmlem toe City of Cupertino agaimd
IA incomena enceof Judgments.cpsu and expenseswhich may In airy way amne agJmtssld City
V z APPS NT UNDE m"
IALS DISCLOSURE Type of Roof
Will tie applicam W future Wilding occupant more m handle hasardons mmerily
u dus¢d by Ih Cupertino Muniripal Code.Chapecr 9.1i,and the HcJN and Sa(edy
ode.Scmian zssTz(a)] All roofs shall be inspected prior to any roofing material being installed.
❑Yes �T10
/\ If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant Imam of future building occupant use a Air and il dMana which P g
emit harvdous Jr crnumimnu u dcfinN by IM Bay Arta Air QrWity Management all new materials for inspection.
District?
Yes �Nu
1 have mad Me hvaNsw mmerinls requiremcnu under Chapnr 693 of the blifor.
nu HeslMkSafmY dc.Sccuw 235(15.2J5JJ arrd 2SSJa.luMmaanA MnifMc Wilding
cmrentl h tenant Mm It u my responsibility W notify the occupant of Me
requi
( Date All roof coverings to be Class';4"or better
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 HOMESTEAD RD BLDG 20A -H
CONTRACTOR: WEST BUILDERS, INC.
PERMIT NO: 09080050
OWNER'S NAME: VILLA SERRA APTS A CA LTD PARTN
1608 4TH ST STE 120
DATE ISSUED: 08/19/2009
OWNER'S PHONE: 6509313457
BERKELEY, CA 94710
PHONE NO: (510) 525-9378
❑ LICENSED CONTRACTOR'S DECLARATION
r— r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. N f�,-2Pj3q5
r r—r
p
Contractor I& y Date d • Z4 '
MECH RESIDENTIAL COMMERCIAL
I hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REVISION: UTILITY CLOSET
(commencing with Section 7000) of Division 3 of the Business & Professions
ORIGINAL: 07120172
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, lbr the performance of the work for which this
permit is issued.
APN Number: 32609056.20AH
Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
correct. l 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
upon the above mentioned property for inspection purposes. (We) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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
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.
Signature Date
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
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
inspection.
the following two reasons:
I, 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations:
1 have read the hazardous materials requirements tinder 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 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 p'orker's Compensation Insurance, as provided for by
Additionally, should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code, for the performance of the work for which this
contaminants as defined by the Bay Area Air Quality Management District i will
maintain compliance with the Cupertino Municipal Code, 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
not employ any person in any manner so as to become subject to the Worker's
�o,-d:
�r�
Compensation laws of California. If, after making this certificate of exemption, I
_ 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
1 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.)
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 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
indemnify and keep harmLss the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
granting 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