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CITY OF CUPERTINO
BUILDING DIVISION PERMITQ11t?�?ks
BUILDING ADDRESS:
20800 HOMESTEAD RD
WEST BUILDERS, INC,
PERMIT NO.
08070025
OWNER'S NAME:
PERMTT L95M DATE
PROMETHEUS
1608 4TH ST STE 120
07/18/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHmiCTBNCIPTEER:
TEMPORARY WATER SUPPLY sc
BUILDING
BLDG ELECTPERPO PLUMBMECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
^� ^ ^ ^ _-- ^ ^^^ ^ ^ J4ahDeseription
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full forces and effect. c
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Date t 67 c� Contractor, ;
.
ARCHITECPS DECLARATION
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 er 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 to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
APN Number
anC
Occupancy
P Y Type
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 sale compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
Required Inspections
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.),
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's U.
cense 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.
n Insurance carrier and Policy number are:
My Worker's Compensation
�t
Carier,�T^ k�E V���LJ Policy No.: -1,5 t- �Z 2-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.)
I cenify,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' Compensaton
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
Lender's 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 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
liabilides,judgmenrs, costs and expenses which may in anyway accrue against said City
of
in consequence of the granti is permit
AP N ERST DS D WILL COMPLY WITH ALL NON -POINT
Issue d b
by:
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Re -roofs
Type of Roof----'
Signs o p lcmut/09tractor ate
HAZARDOUS 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)7
❑Yes rarrJ No
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
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
all new materials for inspection.
District?
❑YesNu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505, 25533 and 25534.1 understand that if the building
e a fen t that I ' my responsibility to notify the occupant of the
does no urtphic
qutrementse511x el r rssuancc of a Certificam of cupancy d
Signature of Applicant Date
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All roof coverings to be Class " `` or better
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owner Date ' '
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