08060205CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
20800 HOMESTEAD RD BLDG 22 WEST BUILDERS, INC.
OWNER'S NAME:
PROMETHEUS
ARCHITECTIENGLNEER:
i o o LICENSED CONTRACTOR'S DECLARATION
u 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 2% 30ij
License Clazs Lic. 8
Dam Contractor
ARCHITECTS DECLAIIATION
I understand my plans shall be used as public records
a
Licensed Professional
y OWNER -BUILDER DECLARATION
g 1 hereby affirm that I am exempt from the Contractors License Law for the
4 C o fa)lowing reason. (Section 7031.5, Business and Professions Code: Any city or county
z m 14Z which requires a permit to construct, alter, improve, demolish, or repair any structure
z prior o its issuance, also requires the applicant for such permit to rile a signed statement
S < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
H (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
a 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 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.).
❑ 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 contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 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 compcn=
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 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:
Cartier:����5��'r Vk—.4 Q> Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars (S100)
orlcss)
1 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' 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
Oforthwith comply with such provisions or this permit shalt be deemed revoked.
""i CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructinn lending agency for the performance of
Yr > the work for which this permit Is issued (Sec. 3097, Civ. C.)
AL.endoes Name
= z L (:ndees Address
Q I certify that I have read 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
U building construction, and hereby authorize representatives of this city to enter upon the
W above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
t7o Idabilides,judgmems, costs and expenses which may in any way accrue against said City
a in consequence of the granting of this permit.
APPLICANT UNDERSAN NO WILL COMPLY WITH ALL NON -POINT
SO /RE/G/ULg7/7`Ojlf/S I X I v
EjAZARDOUS MATERIALS DISCLOSURE
Will the applitlinl or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)7
❑Yes kNo
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 (Sea
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does no ntly ha a ten that it is my responsibility to notify occupant of the
menu w ' m st rior to issuance of s Ceri to of Oc upancy.
6
Owner r ' .e au d gent Dam '
1608 4TH ST STE 120
PERMIT No.
08060205
PERMIT ISSUE DATE
07/18/2008
SANITARY NO. CONTROL NO.
INSTL TEMP WTR SPLY& RETRN
:. Job Description
Sq. Ft. Floor
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
BUILDING PERMIT INFO
ELECT PLUMB
Type
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's" or better