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BUILDING DIVISION PERMITPx„
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a^ Live
WEST BUILDERS , INC .
Bul11IT OMESTEAD RD BLDG 2 # 02
IT NO.
007712 012 0
OW 'S ME:
PMU,4rr LEE DATE
VSIII A CALIFORNIA LTD
1608 4TH ST STE 120
09/26/2008
PHONPT Dmt`Tc7n Vt1_r i1
SANrrARY NO. CONTROL NO.
(510) 525-9378
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with section 7000) of Division 3 of the Business and Professions my license is
In IWT force and eRecL
License CI Lic. f
Date Contractor
ARCHITEG'1'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason- (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to eonatnet, alleti improve, demolish, or repair any structure
prior. to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to !he provisions of the Contractors License Law (Chapter 9
(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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not room than five hundred dollars MOM.
❑ L as owner of the property, or my employer with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 70". Business
and Professions Code The Contractors L40cnse Law does not Apply to an owner of
property who builds or improves thereon, and who does such wort blmseif or through his
own employees, provided thss such impmvematu Lie not intended or offered for seek If,
however, the bolding or improvement is sold within one year of completion. the owner -
builder win have the burden of proving that he did not build or improve for purpose of
sale.).
❑ L as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Businea and Professions Conde:) The Contractor's Li-
eemse Law don not apply to an owner of property who builds or improves themon. and.
who contracts for such projects with a eonuactot(s) licensed pursuant to the Contractors
Ilcense Law.
❑ 1 am exempt under Sec B h P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm miler penalty of perjury am of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Workers Camper -
Won, 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 Workers Compensation Insurarrcc, as required by Section
3700 of the Labor Coda for the performance of the work for which this permit is Issued
My Workers C denWion Insurance ' and Polley number are:
Cartier Polley No.: M 9 00N
CERTIFICATE OF EX I+TfON FROM W ORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is forone hundred down (5100)
or Ins.)
I certify that in the performance of the work for which this permit is issued I shall not
employ arty person in any maancr so as to baonse subject to the Workers' Compeosatlon
Laws of California. Due
Applicant
NOTICE TO APPLICANT. 11. after waiting this Certificate of Exemption, you shouted
became subject to the Worker's Compcnadop provisions of the Labor Code, you muss
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is Issued (See- 3097, Crr. C-)
Lender's Nave
Lenders Address
1 certify that 1 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 missing to
building construction, and hereby sudwria representatives of this city to enter upon to
above-mentiaed Property for inspection purposes.
apse to cave indemnify and keep harmless Lbe City of Cupertino agalmu
liabin odpneat coos and expeosa which may In any way accrue against said City
in panting of this permit.
AAW'U
RSTANDS AND WILL COMPLY WITH ALL NON -POINT
so1oNs. �12rs F5
signatut o Applicant/Connractor V Due
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defied by the Cupertico `Mur 1 Code, Chapter 9.12. and the Health and Safety
Code, section 25532p)7
❑ Yea
WnI the applicant or future b4ilding occupant use equipment or devices which
emit h a=dcus air core umina; as�cllned by the Bay Area Air Quality Management
Diwict7�TV/
❑ Yes o
I have hazardous materials requircmems ur trChapec 695 of the Califor-
nia Heal 1e sty Sections 25505.25533 and 25534.1 understand tut i<tbe building
does not meant, that I Is my resporhdbnfty to 'fy the t of the
req m be prior to Issuance of a ��
(iwneti nr ann nrind anent Date '
Job Description
NEW APT BUILDING 2 A—D 3,219 SF —DOES NOT INCLUDE
ELECT/MECH/PLUMBING.
Sq. Ft. Floor Area $ 0 Valuation
32609029/
Required Inspections
Issued by:
Re -roofs
Type of Roof
Occupancy Type
Date
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 Applicant Date
. All roof coverings to be Class'%" or better