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CITY OF CUPERTINO
PERMIT
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BUILDING DIVISION
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BUILDING ADDRESS:
PERMIT NO.
20800 HOMESTEAD RD BLDG 10 A—
WEST BUILDERS,-INC.
OWNFFS NAME:
PERMIT ISSUE DATE
PHONE:
I A O. CONTROL NO.
nA 0M-Nr
(510) 525-9378
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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.
REV, REBLD STAIRS @EXTNG TO BRNG THEM UP TO CODE
License Class Lick I
Date ri h TGj Contractor '
COMPLIANCE; ORIG #07120162
- 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
Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(commencing with Section 7000) or Division 3 of the Business and Professions Cade) or
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. 10AH
❑ I, 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 forsalo (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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the ject (Sec. 7044, Business and Professions Code:) The Contractor's Li.
tense Law do not apply to an owner of property who builds or improves thereon, and ,
who con c C uch projects with a contractor(s) licensed pursuant to the Contractor's
License w.
❑ 1. e u er ec, B & P C for this reason
Date S_
Owner
ER'S COMPENSATION DECLARATION
I he rm 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
woe for which this permit is issued.
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. Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cnis section need not be completed if the permit is foronc hundred dollars (S100)
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 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.
i
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. Q
Lenders Name
Lender's Address
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
building cons Lion, and hereby authorize representatives of this city to enter upon the
abovc•mentim property for inspection purposes.
(We) a to save, indemnify and keep harmless the City of Cupertino against
j liabilid ,jud ts, costs and expenses which may in any way accrue against said City
in con tree C ranting of this permit.
APPLI N ER ANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR RE L ION
5
'S
Re -roofs
Type of Roof
Signam a of ICIntl actor Date
ZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupanlstore or handle hazardous material
as defined by the Cupertino Muqieipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?]/
All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
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 ha'rardous air contaminants �Rdefrned by the Bay Area Air Quality Management
all new materials for inspection.
District?
Nu
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zardousmarerialsrequirements undcrChapter 6.95oflheCaliCor•
nia HealthSections25505,25533and25534.1understandthatifthebuilding
&SKodc,
doesa tenant. that it is my responsibility to notify the occupant of the
requt be met prior issuance of cenffieam of ocyparh _.
Signature of Applicant Date
All roof coverings to be Class',n"' or better
Dale
Owner �cdagent