07120155CY OF CUPERTINO
BUILDING DIVISION PEPMUT
BUILDING ADDRESS:
20900 HOMESTEAD RD BLDG #_ qjj WEST BUILDERS, INC.
VILLA SERRA APTS A CA LTD
4&7% V rMT _
ARCHT ECr/FNGINEER
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am Iimnaed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
In full fora and effecL
(.leant", Cl: Lk. I
Doc Contractor
[TECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 703 L.5. Business and Professions Code: Any city or county
which requires a permit to construc4 alto improve. demolish. or repair any auucture
prior to its issuance. also requires the applicant for such permit to file a signed suemen
thu he is licensed pursuant to the provisions of the Contractors License law (Chapter 9
(commenting with Section 7000) of Division 3 of the Business and Professions Coda) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by an applicant for a permit subjects the applicant to a Civil penalty of
not mom them rive hundred dn1Lm (S500).
❑ L as owner of the property, or my employees with wages as their sole compensation,
will don the work. and the structure Is not intended or offered forme (Sec. 7044, Business
and Professons Coda The Contractors License nse Law does not apply to an owner of
property who builds or improves thereon. and who does such work himal or through his
own employees, provided drat su b improvements sae not intended or offered forsale. If,
however, the building or improvement is sold within one yea of completion. the owner -
builder will ban 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 70". Business erred Profession Coda) The Contractors Ll-
cease Law does not apply to an owner or property who builds or improves dhemon, and
who contracts for such projects with a conawtor(s) licensed pursuant to the Contractors
I k-,— Law.
❑ 1 am exempt under Sec B $ P C for this reason
Due
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dcdmd s
❑ I have and will maintain a Cenifiate of Consent to self -insure for Workers Compen.
Won. as provided for by Section 3700 of the Labor Code, for the pufmrnamx of the
work for which this permit is issued
❑ I have and will maintain Workers Compensation Insurana, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit Is Issued.
My Worker's rope uion lrunnnca carries tad Policy nun ate
Carrier: 'G Polley No.: nl,16604-11
CE11I7FICATE OF EXEMPT30N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed Ir the permit it for one hundred dollars (310a)
or less)
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 Worked (bmpuuuWou
Lam of California. Dam
Aphplianl .
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become Subject to the Workers Cermpeusadon provisions of the Labor Code, you must
forthwith comply with such provisions or this pea nit shall be d=med revoked,
CONSTRUCTION LENDING AGENCY
1 Mmby affirm that There is a construction leading agency for the performance of
the work for which this permit Is issued (Sec 3097, Civ. C.)
Lenders Name
Landers Address
I certify that I have lad this application and sure that the above information is
correct. I agree to comply with all City and county ordinances and sue laws relating to
building construction, and hereby sutiwrim representatives of this city to enter upon she
ahwve men shed property for Inspection purposes.
(w to save, indemnify and beep harmless the City of Cupertino against
liabilities, ts, costs and expenw which may In any way accrue against said City
in the granting of this ptrmlL
AP ERSTANDS AND WILL COMPLY ALL N N-POINT
S ONS. C 2
�1
signature t/Contractor Due
HAZARDOUS MATERIALS DISCLOSURE
WW the applicant or future building occupant atom or handle hazardous material
as deflnxd ly the Cupertino Mum 'pal Conde Chapter 9.12 and the Health and SafetyCode. Seaton 25532(a)7
❑ Yes No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air eonumlnun tIL defined by the Bay Area Air Quality Management
District? �j/
❑ Yes No
1 the lsaardadus manerials requirements under Chapter 6.95 of the Califor-
rtiaHeslth aka ode. Scaiau2iSf1S.23533and25534.1urhderautddutlfelrbuildieg
deer a tananL der it is my revpondbility to notify the occupant of the
requ n w h be reel prior to issuance of a Cenif�
Owner or agent Date ' .
1608 4TH ST STE 120
(510) 525-9378
PERMIT NO.
07120156
PERMIT ISSUE DATE
09/26/2008
SANITARY Na CONTROL NO.
BUILDING PFRMIr INFO
BLDG ELECT PLUMB MECH
Job Description
NEW APT BUILDING A—D 3,2191
8/25/08 SEE #07120212 FOR SUBS
Sq. Ft. Floor Area 1 $ 5 5 5 5 5 5 Valuation
32609029'
Required Inspections
Issued by:
Re -roofs
Type of Roof
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