07120121N OF CUPERTINO
BUILDING DIVISION PEPMM
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BulIrMMOMESTEAD RD BLDG 3 A-D I WEST BUILDERS, INC.
OWNER'S NAME.
VILLA SERRA APTS A CA LTD 1608 4TH ST STE 120
ARcHrreCrfENGINEFR:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I um licensed wrier provisions of Chapter 9 (commencing
with Section 7000) of Divisioa 3 of the Business and Professions Code. and my license is
in full fora and drat S
License Class [.1e. r
Dam 1_ . ,. contract"
�1�rrECTS DECLARATION it
1 understand my plans Shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 1.1canse Lair for the
following mason. (Section 7M IA Business and Professions Code: Any city at county
which requires a permit to construct. alter, improve, demolish, or mpair any Structure
prior to its issuance. also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's 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 more than five hundred dollars (3300).
❑ L, as owner of the property, or my employers with wages as their sole compensation.
will do the work and the structure Is not intended or offered for sale (Sec. 7044. Business
and Professions Code The Contractors L.icenae Ire does not apply to an owner of
property who builds or improve thereon, and who does such work himself or ihroegh his
own employcM provided that Stich 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 Wild or improve for purpose of
sale.).
❑ L u owner of the property. am ndusively contnaing with licensed caatrttcilm to
construct the Project (Sec. 7044. Basin and Professions Code:) The Contactors Li-
ceuse Law don not apply to an owner of property who builds or improves thereon. and.
who contracts for such projects with a coniraeto*) licensed pursuant to the Contractors
L k== Law.
❑ 1 am arempt under See. B h P C for this reason
Owner Dale
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Udw Codr, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required red by Section
3700 of the Lobar Code, for the performance of the work for which this permit Is Issued.
My Workeree amp naarioa�arrier and Policy number are:
'G +�
Cartier Policy No.: —7 P 9 boo I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nds section need rot be completed if the permit is forone hundred dollars (310fp
or lea)
I certify that In the performance of the work for which this permit is issued, ) shall not
employ any person in any manner so as to become subject to the Worked Compenaulon
Laws of California. Due
Appliont
NOTICE TO APPLICANT. If, after making this Certificate of E npdm, you should
become subject to the Wards Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed rooked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm than there is a construction lending agency for the perfamana of
the work for which this permit is issued (Sec 3097, Civ. Q
l.endees Name
Laxices Address
I ratify dot I have.read this application and state that the ,hove information is
conect. 1 agree to comply with all city and cm mty ordinances and state laws relating to
building construction, and bemby authorize representatives of this city to enter upon the
above-menti property for inspectiea purposes.
to save, indemnify and keep harmless the City of Cupertino against
liabilities, j is. costa and apeates which may In any way accnuc agalmtt said City
in cortaeq o granting of this permit.
AP C STANDS AND WILL COMPLY2ALL ON -POINT'
So ONS.
• Q h
Signature k4pplicanjontractor Date
'RAZARDOUS MATERIALS DISCLOSURE
WW the applianL orfutore building oceupamL core orhandle hazardous mamrial
as dented by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Sectlon 25532(a)7
❑ Yes
Will lhu applicant or fut re building occupant use equipmem or devices which
emit hvardous air costa in•�rncd by the Bay Area Air Quality Management
Diurict7
❑ Yes o �T/t read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Pa44 do WeLyCodc, Sections 25505.25533 and 25334. I understand that if due building
t tly have a rant, rat It is my responsibility to notify the occupant of the
h meat er
be met Prior to issuance of a Certif>
wrhorisrd aunt Data
(510) 525-9378
PFRMrr NO.
07120121
PERMIT BELIE DATE
09/26/2008
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BL.DC ELECT PLUMB
Job Description
NEW APT BUILDING 3 A-D 3,2191 SF
8/25/08 SEE #07120212 FOR SUBS.
Sq. Ft. Floor Area $ 5 5 5 5 5 5 Valuation
32609029!
Required Inspections
Issued by:
Re -roofs
Type of Roof
Type
Date ri L.G-C__2�
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'R" or better