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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
U, HOMESTEAD RD, BLDG 63A -H
WEST BUILDERS, INC.
PERMIT NO.
07120184 .
NER•S NAME:
PERMIT ISSUE DATE
VS 11 A CALIFORNIA LIMITED
1608 4TH ST STE 120
07/14/2008
1110NE\I7 r)TT
SANITARY NO, CONTROL NO.
AR CH17ECTAENGINISER,
BUILDING PERMIT INFO
REMODEL -NEW DECK RAILS, BLDG ELECT PLUMB MECH
O O O O
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hmcby affirm dart 1 m ii¢ udcr pmvfalam of amPW 9 (=Mm Ag
"""""""" "--- --"
wish Section ]IXIU) o' U' "'on 3 ofNe Buunem sculptor Code. and my license is
in ren forte and efrem. -L �-
License as L'c, d
Dat, Contractor
,
ARCM' DECLARATION
1 undetected my plans Nall he used as public racodm
Licensed PwfCasmoul
OWNER -BUILDER DECLARATION
1 hereby aRrm than I am exempt focus she Conlramors License law for do
following mason. (Section 7101.5, Business and Professions Code: Any city or County
which mquims • Permit to eonuweL alar, impaw, dermal W, m repai, any wuctuus
Prior w it, issuance. Ow requimi the applicant for wch permit to file a signed statement
• to Nc of the Contractors lJcemse Law(Chapte 9
he is licensed
Sq. Ft. Floor Area
Valuation
that pnrwant pmrisiom
(commeneing'wiN Section 7000) of Owision Sar she Brain••• and Professm. Code) or
Nat k u exempt shertfrnm and Ne bss6 for Ne alleged eremption. Any violation of
APN Number
Occupancy Type
P y YP
Section 703" by any applicant for. permit wbjecu do applicant to a Buil penalty of
not mom than five hundred dollars (1300).
❑ I.uowst,r of tic pocpury, or my umployw wish wgesssticr ante campcnution,
Required Inspections
will do Nework, and Ne swmum 4 notintended croRered formate (Bee. ]014. Buai"•..
and Pmremsiom code The Contractors Lv...» Law does not apply to sm owner of
Property who Wilda orimpross thereon. and who doessuch werkhimselfmr through his
awns employuu, proWded out wch improwmanta tie rot int,eded oroRertd for sale B,
howcwr, Ne Wilding m impwwmann uwld within oro yeti of Completion, Ne awe
builder MB of
ehaw Ile burden of proving Nak t did nes WiW m hormone far purpose ar
role.).
❑ 1. as oww of the propcnY• am eaGusiwly contacting wish licensed cmnttacnoa or
Comtrum tk project (See 7144. Business and Profesaiom code:) The conraemra U.
.
Cane law does not apply to an owner of property, who Wilds or Wproves thereon. and
who Contracts for such pocjecm with a canuamor(s) liccmed Pearson, to the Connors
License law.
❑ I sus esuopt under See .B k PC for Nis rtawo
nv Dat,
WORKER'S COMPENSATION DECLARATION
I bemby afOm under penalty of perjury oro of the following declnNmmc
❑ 1 have and will enunuin • Cenifinmof Caromm to self imurt fmworlm"Compcn-
adan, as provided for by Session 3700 of Ne Labor Cade, for Ne performan a of the
work for which this Permit is issued
❑ 1 law and will maintain Watkers Compensation Imran¢. a nNuimd by Socuon
3700 ofthe, Labor Code, for the perrarmancc of she work for which this Permit is issued.
'
MY W s Pe1pw'oo bru�urwm Cartier and Policy num �a ��^�G�
Grtier. nm 7 Y / PoRcy No.: � f
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(f7dsseedon need not W conpleed Bede permit is foronehundrnd dMars (x10%
or leu)
1 certify shat in the perform. of Ne work for which this peri, is issued. I shall am
Cmploy any'cous in any enaoncrw as to boom. bj.11. the workers' Compewtion
Laws of California. Due
Applicant
NOTICE TO APPLICANT: If. ares making this Cenificae of Exemption, you should
baome subject to Ne Wohers Compensation psovisiom of the Lator Code, you mut,
forthwith comply wish wch provisiam w that pewit Nall k deemed rtrokcd
I
CONSTRUCTION LENDING AGENCY
1 knobby affirm shat tkrt u a Comrsc,ion lending agency for she perromance of
she work (m which this pewit B issued (Sec. 3097, Civ. C.)
Lenders None
Lenders Addmv
1 custifY Nat I haw red this application and that, Nat the aWw informauun is
comm I agree to comply, with all City and county sediment and stale Was miming to
Wilding construction. and bee by mmortan resprtsanhatiws of this city b corer upon Ne
ahuve srcd pocpe for inspection Pmpswhich
(We) agree to s.w, indemnify and keep harmless she City of Cupertino against
ms
lea, costs
onha, couand eapemeswhich may in any mya,rnc.gaimt and City
in
in conaequenee or she ganunj of this permit
LICANT {( 11 RSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dale
S
D
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Ne,pplicant ar future Wilding oCwPantunw or Weak hanadous mamrial
as defined by tic Cupertino Mterskiful Code. Chapter 9.13. and Ile Heads and Safety
Suction 25532(a)7 ❑rat
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Yoram building occupantoccupanttaw equipment or devicca which
If a roof is installed without first obtaining an inspection, , I agree to remove
P $
emit havadam all Contaminants as de0ned by she Bay Area Air Quality Management
all new materials for inspection.
P
Diuno7
❑Yes No
1 hent red Ne harsmw, materials rnq.irtmonu under Chapter 6.95 of ft Califor-
nuHealth A,S.fnyCode, Sections 25505.25533 and 25534.1 unduuwE Nn ifthe Wilding
does has Co.nlb Wan an. unanL Nal i, is my rtspomimility m Iwdfy Nc IXCrpant of Ne
sin ,g n, Dam
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 HOMESTEAD RD BLDG 63A -H CONTRACTOR: WEST BUILDERS, INC. PERMIT NO: 09080084
I OWNER'S NAME: VILLA SERRA APTS A CA LTD PARTN 1 1608 4TH ST STE 120 1 DA'Z'E ISSUED: 08/19/2009 1
OWNER'S PHONE: 6509313457 1 BERKELEY, CA 94710 1 PHONE NO: (510) 525-9378 1
❑ LICENSED CONTRACTOR'S DECLARATION
License Class CAA_Lic. # �ZS�is
Contractor ( Date
1 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.
I 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.
I 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
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. 1 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
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
9.18.
Si
Date �%f"
❑ OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
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
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
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.
I 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
permit is issued.
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
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
forthwith comply with such provisions or this permit shall be deemed revoked.
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
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,
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
9.18.
Date
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB T_
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION:REVISION UTILITY CLOSET
Sq. Ft Floor Area:
Valuation: $2500
APN Number: 35609056.63AH I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
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
inspection.
Signature of Appl
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
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
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner
Date: A 2T
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional