08060212CITY OF CUPERTINO
BUILDING DIVISION PERIVIITd1JkTCTZ-�'�£T*
BUIL I G D ESS: PERMIT NO
HOMESTEAD RD BLDG 13 WEST BUILDERS, INC. 080b0212
OWNER'S NAME: PERMIT ISSUE DATE
PROMETHEUS 1608 4TH ST STE 120 07/18/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: INSTL TEMP WTR SPLY& RETRN BLDG BELE�G PERMIT INFO MFC14
LICENSED CONTRACIDRS DECLARATIUN
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
License Clas Li . N ,,� Z�
Date Contmcioi—
A CHITECfS DECLARATION
I 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 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 requites 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, ax 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 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 Sea B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I 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'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 Umber am:
Cartier. 1�0H� Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit 1s 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 manner so as to become subject to the Workers' Compensation
Laws of Califomia. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation previsions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall be deemed mvoked.
CONSTRUCTION LENDING AGENCY
1 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.)
L.endces Name
Lender's Address
I certify that 1 have mad 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
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence "'the
granting of is pa it
APPLICANT UNDERSTAND AN LL COMPLY WITH ALL NON -POINT
SO L S. u u
Signature A Con for Date
HAZARfJoUS 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 Safely
Code, Section 25532(a)?
❑ Yes �No
Will the applicant or fuwre building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
C] Yes No
1 have read the hazumioluuss materials requirements under Chapter6.95 of the Cali for-
nia Health &Safety Code, Sections 25505,25533and 25534.1understand that ifthe building
does not currently have a nant t it is my responsibility to notify occupant of the
requirements which u A r to issuance or a crditca of oc ty.
� o
Owners nrizrA'a m Data '
Floor
Number
Issued by:
Re -roofs
Type of Roof
Job Description
Required Inspections
Occupancy
Date / l,'"
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