08060191W
BUILDING DIVISION PERMIT t�tll�1J Jlf�t1`
)ING ADDRESS:
?0800 HOMESTEAD RD BLDG 48 WEST BUILDERS, INC.
OWNER'S NAME:
13ROMETHEUS
ARCHITECT/ENGINEER:
1 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
in full force and effect. sg t q5
License Class Lic. 8
Date ni t—Contmcto
ARCHITELrSDECLARAIION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to conswc6 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 Caw (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 rive hundred dollars ($500).
0 I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the suuclure is not intended or offered forsalc (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, pmvidcd that such improvements are not Intended oroQered forsale. 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 Conbacuies U.
came 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.
0 1 am exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
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 Worker's Compensation Insurance carrier and Poli nuem�bar am -
Carrie
r��'%PiCF TLl��c) PolicyNoM V 2b
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
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 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
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.)
Lenders Name
Lenders Address
,I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorim representatives 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
Iiabilities,judgmems, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Signalup'Jo4cripfli onuacZARDS MATERIALS DIS
tor ' f Date
AOUCLOSURE
Will the app scant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9,17, and the Health and Safety
Code, Section 25532(a)?
[] Yes �[}•No
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?
(3 Yes Iro
1 have mad the hamidous materials requirements under Chap ter6.95 of the Cal Ifor.
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not curenlly haw tenan4 That It is my responsibility to notif the occupant of the
requ w' h m t prior toQance f a Certifighta
nnof CNkpancy,
Owner or a zc agent V Date
1608 4TH ST STE 120
PERMIT NO.
08060191
PERMIT ISSUE DATE
07/18/2008
SANITARY NO. CONTROL NO.
BUILDING PERMrrINFO
INSTL TEMP WTR SPLY& RETRN BLDO EO PLUMB ME�CH
r ..� Job Description
Sq. Ft. Floor
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy
Date 2f
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