08060172BUILDING DIVISION PERMIT
PERMIT NO.
OMESTEAD RD BLDG 64 WEST BUILDERS, INC. 1 08060172
OWNER'S NAME: PERhIIT ISSUE DATE
PROMETHEUS 1608.4TH ST STE 120 1 07/18/2008
ARCHITECT/ENGINEER:
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70W) of Division 3 of the Business and Professions Code, and y license is
In full force and effect
License" �Claz� Lam• N
DatcF� ) /j_ Contractor
CHITECTS DECLARATION
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
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 ($500).
❑ I, as owner of the property, or my employees with wages as their sale compensation,
will do the work, and the structure is not intended or offered forsale (Sec.7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for We. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sea B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Cartificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the labor Code, Cur the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
\
Cartier, R)t E'>Policy No.
CERTIFICATE OF PITON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($I00)
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' Compensatan
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you should
become subject to the Workcrs 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.)
Lendces Name
Lender's Address
I certify that I have lead this application and state that the above information is
correct. 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 enter upon the
above -mentioned properly for inspection purposes. ,
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in anyway accrue against said City
in consequence of thAgR
'mit.
APPLICANT LINDWILL COMPLY WITH AL NON -POINT
EG SigmapplicaERIALS DISCL SURE
Will the applig 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)?
❑ Yes No
Will the applicant or Cut re building occupant use equipment or devices which
emit hazardous air contaminants as dcftncd by the Bay Area Air Quality Management
District?
❑Yas �No
I have read the haranious materials requirements under Chaptcr6.95 of the Califor-
niaHeaith&SafetyCodc, . 25505,25533and25534.lunderstandthatifthobuilding
does not curently ha that it is my responsibility to notify cupanl or the
requi ust 'or to issuance of a crtificatc f Occup
Owner or auth '7;ag Date '
SANITARY NO.
INSTL TEMP WTR SUPLY&RETRN
T?iSI 1T m Try
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Job Description
Sq. Ft. Floor
Required Inspections
Issued by:
Re -roofs
Type of Roof
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
Valuation
Occupancy
Date %�= G%•
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'n" or better