07120111BUILDING DIVISION PERMIT
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STELLING RD, BLDG 51
VILLA SERRA APTS A CA LTD
ARCHITECTIENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business d Professions Code,/and my license is
in full force and effect. i. � `
License C s �— Lie. # • "�
Date Contractor_
ARCHITECTS DECLARATION
—
I understand my plans shall be used as public records
Licensed Professional i
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requites a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile 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 (S500).
❑ 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 Contractor's License Law does not apply to an owner of
property who builds orimproves thereon, and who does such workhimself 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.).
Q 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's 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) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sea B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insum for Worker's 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 Worker' Co nsau(op•-Insurance carder and Policy number are:
Carrier.
Y�`^°,J� Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is forone hundred dollars ($100)
or Icss)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any mannerso as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this CCrtificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
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 (Sec. 3097, Civ. C.)
Lendoes Name
Lender's Address
1 certify that I have mad this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws mlating to
building construction, and hereby authorize representatives of this City to enter upon the
above-m 'coned properly for inspection purposes
agice to save, indemnify and keep hornless the City of Cupertino against
IiabiliU gments, cosy and expenses which may in any way accrue against said City
in c nse n Cf the granting of this permit.
AP IC NT DERSTANDS AND WILL COMPLY WITH ALL iLON-POINT
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Signature UConttactar ►' Date
HAZARDOUS MATERIALS DISCLOSURE
r a applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Muni ' al Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes No
Will the applicant or future utlding occupant use equipment or devices which
emit hvardnus air contaminan s defined by the Bay Area Air Quality Management
District?
cs Nu
1 a d the hazardous materials requirements under Chapter6.95 of the califor-
ma cal afc Code, Sections 25505,25533 and 25534. 1 understand that ifthe building
d not u n vc a tenant that it is my raponsibilily toh-�
uy the upant of the
reyu m w 'ch ust be et prior to issuance of a Ccrufic Occu an
Owner or gent , Date
WEST BUILDERS, INC.
1608 4TH ST STE 120
(510) 525-9378
NEW APT BLDG, BLDG 51
8/25/08 SEE #07120212
Ft.
32609056 —
Issued by:
Re -roofs
Type of Roof
PEItMf f NU.
07120111
PERMIT L95UE DATE
09/26/2008
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
a o 0
Job Description
A—B, 2300SQ
FOR SUBS
$555555 Valuation
Required Inspections
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