08060171BUILDING DIVISION PERAUT
?zoo
7 4
•wy
;off
� N
.Qo
<�
'za
�sF eQ
BUIL G D ESS: - PEx MITNU.
�i��(� HOMESTEAD RD BLDG 66 WEST BUILDERS, INC. 08060171
OWNER'S NAME: PERMIT ISSUE DATE
PROMETHEUS 1608 4TH ST STE 120 07/18/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
I 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 t� 5'
License Clas Lie. N
Date Contractor
CHrrEcrsDECLARATI N
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 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 repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant io 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 Eve 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 fer 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 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.).
❑ 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.
sense 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 See. 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 Worker's Compensation Insurance carrier and Policy nu er am:
Carler�� 3 Policy No.: `
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($I00)
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 mannerso as to become subject to the Workers' Compensadon
Laws of California. Dale
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
Lender's Address
1 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 Conswction, and hereby authorize 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
liabilities, judgments, costs and expenses which may in anyway accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTA S AND WILL COMPLY WITH L NON -POINT
SOU LA S.
Signawr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hwzardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes )CIo
Will the applicant or future building occupant use equipment or devices which
emli hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes No
1 have read the hazanious materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
li does not curendy have a nano that it is my responsibility to tify pant of the
mqui is whi us dor to issuance a Cc 'fic ref Occu
( Owner auth a nl _ Date
BUILDING PERMIT INFO
INSTL TEMP WTR SUPLY&RETRN BLDG ELECT PLUMB
Job Description
Sq. Ft, Floor Area
Required Inspections
Issued by:
Re -roofs
Type of Roof
Type
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'n" or better