08060189BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
20800 HOMESTEAD RD BLDG 55 WEST BUILDERS, INC. 08060189
OWNER'S NAME: PERMIT ISSUE DATE
PROMETHEUS 1608 4TH ST STE 120 07/18/2008
PHONE;
SANITARY NO. CONTROL NO.
ARCHrMCr/ENGINEER: BUILDING PERMITINFO
INSTL TEMP WTR SUPLY & RET BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700W) of Division 3 of the Business and Professions Code, and my license is
in full force and effect. 5
License CI s Llc. N
Dar Contracto
RCHITECI'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
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 requires a permit to construct, alter, improve, demolish, or mpair_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 taw (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 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 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.).
❑ 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 L)-
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 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 Certificate of Consent to self -insure 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 Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier.Policy No.:
CERTIFICATE OFPI70N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (f 100)
or less)
I certify that in the performance of the work for which this permit is issued,) 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 Certificate of Exemption, you should
bec9me, 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.)
Lender's Name
L.endees Address
1 certify that I have read this application and stale that the above information is
correct. I agree to comply with all city and county eminences and state laws relating to
building construction, and hereby authorize represemadves of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the gran ' g of this permit.
APPLIC RS ANDS AND WILL COMPLY WITH AL NON -POINT
SOU E REGU TI0
Signature App icanVC 'tractor birte
H ARDOUS 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)?
b Yes XNo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? ,
❑ Yes DY+ o
I have mad the ha7mdoVus materials requirements underChapter6.95 of the Califor-
nia Healdi &Safety Codc, Sccdons 25505, 25533 and25534. I understand that if dic building
does not currently have a' tenant. at it is my responsibility to odry time upent of the
requiremen must be me de lssuance of a Cenific g( u cy.
o
Owner or autho agent Z
Number
Issued by:
Re -roofs
Type of Roof
Job Description
Required Inspections
Valuation
Occupancy
Date rc/
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 'A" or better