08040230BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
20800 HOMESTEAD RD, BLDG 12A-H WEST BUILDERS, INC. 08040230
OWNER'S NAME:
VS II A CALI
PHOt5;N P rpm
ARCHrCEC-/ENGINEER
u oo zo LICENSED CONTRACTOR'S DECLARATION
,U I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
y in full force and effect i
j ? License (lass C.'X� Lk. C
� Dam_ •4,- C Z Contractor 400 - P
aRCHITECI'S DECLARATION
eke I understand my plans shall be used as public records
�yU
iLicensed Pmfcssional
rn OWNER -BUILDER DECLARATION
�yt i hereby affirm that 1 am exempt from the Contractors License Law for the
i ap O following reason. (Section 7031.5, Business and Pmfessioas Code: Any city or county
K $ which requires a permit to construct, alter, improve. demolish, or mpair any structure
Zy„ prior to its issuance. also requires the applicant for such permit to file a signed satement
Ss < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
F $ (commencing with Section 70DD) of Division 3 of the Business and Professions Code) or
y 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 (5500).
I, 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
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such 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 build or improve for purpose of
sale.).
I. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code.) The Contractors Ll-
ccnse Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner - Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen.
sation, 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worlce[�sCompensation Insurance carrier and Policy number arc
Carrier: vQ_ 0 Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS,
COMPENSATION INSURANCE
(-his section need not be completed if the permit is for one hundred dollars ($10D)
or less.)
I 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 Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after malting this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code. you must
.J O forthwith comply with such provisions or this permdeemed
it shall be ded revoked.
7— CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency ror the performance of
CY. the work for which this permit is *issued (Sec. 3097, Civ. C.)
a Q Lenders Name
Lenders Address
U C I certify that I have read this application and state that the above information is
V. F conacL I agree to comply with all City and county ordinances and sate laws relating to
0 C.) building construction. and hereby authorize Representatives or this city to enter upon the
Uabove -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
H926,
rA Iiabilides, jodgmcats, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO7RE r
Signature of Applicant/Conusctor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mumi 'pal Code. Chapter 9.12 and the Health and Safety
Code, Section 25532(a)?
❑ Yes No
Will the applicant or future building occupant use equipment or devims which
emit hazardous air contaminants as toed by the Bay Area Air Quality Management
District?
❑ Yes o
1 bave read the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health & SafctyCode. Sections 25505, 25533 and 25534, I understand thatif the building
does not �Cyy¢¢��ntiy have a tenant that it is my responsihitity to notify the occupant of the
requincmk(tt.{-whi met prior to issuance of a Car dfrcatc of Occupancy.
Owner or authorized agent �• Dare
PERMIT ISSUE DATE
1608 4TH ST STE 2008
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
UNDERGROUND WATER PIPE ONLY BLDG ELECT- PLUMB MECH
PUR NEW _Job Description
Sq. Ft. Floor Area Valuation
APN Number Occupancy Type
Required Inspections
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing material Ceing 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 "B" or better