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CITY OF CUPERTINO
DIVISION
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BUILDING PERMIT
BUi1.�ING DRESS:
PERMIT NO.
G0��0 HOMESTEAD RD, BLDG 60A—
WEST BUILDERS, INC.
08040236
OW 'SNAME
PERMrTISSUE DATE
VS II A CALIFORNIA LIMITED
1608 4TH ST STE 120
05/05/2008
PHONE?h o mrT
SANITARY NO. CONTROL NO.
(510) 525-9378
ARcHrTECTfENGINEE L
BUILDING PERMIT rNFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70DU) of Division 3 of do Bushicss and Professions Code, and my licemic is
UNDERGROUND WATER PIPE ONLY FOR NEW WATER
force and erreet L ruts aG.S IL Lk. r 2S 6y ll
License Class '
HEATERS —DOES NOT INCLUDE GAS OR ACTUAL WATER
HEATERS. NEEDS SEPERATE PERMITS FOR THOSE.
Daic ` n pi>1M5rN
ARCHTTECTSDDEECLARATIONANt
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that i 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 construct, alter. improve, demolish• or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
is licensed to the Contracmr9 License Law (chapter 9
Sq. Ft. Floor Area
Valuation
that he pursuant provisions or the
15 0 0 0
(commencing with Section 70D0) 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
3 2 6 0 9 0 5 6 '°6�.� umber
Occupancy Type
Section 703M by any applicant for a permit subjects the applicant to a civil penalty of
not mom than rive hundred dollars (too).
❑ 1, as owner of the property. or my employees with wages as their sole compensation,
Required Inspections
eq
win do the worm and the structure is not intended or offered for sale (Sm 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 wort 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 bald or Improve for purpose of
sale).
❑ 1. as owner of the property. am exclusively contracting with Ucrosed contractors to
conmuct the project (Sec 7044, Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licen d pursuant m the Contnelors
LicenseLaw.
❑ T am exempt under Sec B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I hire and will maintain a Certinrate 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
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
370D of the labor Codc, for the perfomuna ed. of the work for which this permit is issu
My Worker Co; mpensauon insurance carrier and Policy number are:
Curter. rJQ.-7 Policy No.: 2
—'
CERTIFICATE OF FJ EMPI70N FROM WORKERI'
COMPENSATION INSURANCE
0-his section need not be completed if the permit is fexone hundred dollars ($100)
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 Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this peaoit shall be deemed revoked.
I
'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which Otis permit is issued (Sec. 3097, Civ. C.)
( Lenders Name
Lenders Address
I certify that I have read itds application and state that the above information is
' cmrcm 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 era upon the
( above -mentioned property for inspection purposes.
10
(We) agree to save, indemnify and keep harmless the City of Cupertino against
I liabilities, judgments, coats and expenses which May in airy way accrue against said City
in consequence of the granting of this permit.
UND DS AND WILL. COMPLY WITH All. NON -POINT
Issued by: Date S e ��
so so
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Re -roofs
Type of Roof
t 1i
Sigmfim o ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)? �n /,
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes VNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building oceupamt use equipment or devices which
emit hazardous air contaminants as damned by the Bay Area Air Quality Management
all new materials for inspection.
District?
MNo
❑ Yes
I have read the hazardous materials; requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand the if the building
does notTly harea tenant. titis my responsibility m notify the occupant rf the
'
regrirehnmn m r issuance of a Cenificacate of Occupancy.
Signature of Applicant Date
J $-• 6 -r8
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All roof coverings to be Class'A' or better
Owner orauthorbcdagent Date