090100914 C4z
�yUU
U
W
'7Z
WQ
`ry0
a
n
qC
�Z>
EFC
0C
L>! 5
W~
a
�z
UC
wE_
� L
�a
UZ
CITY OF CUPERTINO
DIVISION PERIVIIT��T3.I���k�
BUILDING
BUILDING ADDRESS:
PERMIT NO.
20800 HOMESTEAD RD
WEST BUILDERS, INC.
OWNER'S NAME:
PERMIT LSSUE DATE
PHONE:
S A CONTROL NO.
(510) 525-9378
ARCHITECT/ENGINEER:
BUILDING PERMITiNFO
BLDG ELECT PLUMB - MECH
o co 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(X)) of Division 3 of the Business and Professions Code, and my license is
in full force and effect e1 !.J
DEFERRED PRE-FAB METAL STAIR
DatcLiccnsc ss Contractor lNS�i? i)
SUBMITAL-ORIG#08030156
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I 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 requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the previsions 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 Cade) or
$ 8 O O O 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than rive hundred dollars ($500).
3 2 6 0 9 0 5 6. ALL
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure Is not intended or offered for sale (Sec. 7044, Business
and Professions Cade: The Contractors License Law does not apply to an owner or
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 Contractors 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 (he Contractors
License Law.
❑ 1 am exempt under Sec. , B & P C for this reason
Owner Dale
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 Workers 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
'
My WorkeessCLompensation Insurance carrier and Policy number am: ark
5� t, 1�kd Policy No.; 75_W 892
Cartier.
CERTIFICATE OF EXEMP770N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone 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 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
(he work for which this permit is issued (See. 3097, Civ, C.)
Lenders Name —
Lenders Address
1 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
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 any way accrue against said City
in consequence of the of this permit.
k
granting
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC EG LATIONS, .
— -
�.—
Re -roofs
Type of Roof
Signat of Applicam/Contractor Date
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)?
No
All roofs shall be inspected prior to any roofing material being installed,
❑ Yes fA
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? `•
❑Yes ®,Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &SafetyCode, Sections 25505,25533 and 25534. 1 understand that ifthe building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requireme+ It must be met p 70 issuance of a Certificate of Occ p y
/
Signature of Applicant Date
/ ' w. f
All roof coverings to be Class'n" or better
Date '
Owner thorixcd agent