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CITY OF CUPERTINO
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BUILDING DIVISION
BULL I G D ESS:
TME) N STELLING RD, BLDG 39
WEST BUILDERS, INC.
PERMIT NO.
07120129
OWN 'S AME:
PERMIT ISSUE DATE
VILLA SERRA APTS A CA LTD
1608 4TH ST STE 120
09/26/2008
ACNE,\ ---
SANITARY NO. CONTROL NO.
(510).525-9378
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business spy rImiiions Codc, an y license is
NEW APT BLDG , BLDG 3 9 A—J , 8027 _S Q
in full farce and offecL �'7
LIensecl Lic.N
8/25/08 SEE #07120212 'FOR SUBS
Date Contractor
ARCHITECTS DECLARATION
1 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 mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
Sq. Ft, Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
Contractor's License Law 9
that he is licensed pursuant to the provisions of the (Chapter
$ 5 5 5 5 5 5
(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
3 2 6 0 9 0 5 6 Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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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 dues 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 contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec. , 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.
My Workees.Com ensaIian lnsuran carrier and Policy number are: A�
Pal icy No �o &)Ace L
Cartier.
CERTIFICATE OF XEMPTION FROM WORKERS'
COMPENSATION INSURANCE'
(This section need not be completed if the permit is foronc hundred dollars ($100)
or less.)
I cerify 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 or the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance or
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lenders Name
Lenders Address
j I certify that I have read this application and state that the above information is
r correct I agree to comply with all city and county ordinances and state laws relating to
hereby authorize representatives of this city to enter upon the
t building cankpfu�ry
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above for inspection purposes.
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(We), indemnify and keep harmless the City of CupeNno against
I liabilides,jus and expenses which may in anyway accrue against said City
nquentingofthispermit, L AANDS AND WILL COMPLY WI ALL ON -POINT
Issued by: Date �.�SOU
ER
Re -roofs
Signature of UCo ractor Date.
H RDOUS MATERIALS DISCLOSURE
Type of Roof
Will t or future building occupantstorc or handle hazardous material
'
asdefined by Ore Cupertino Muni ' al Codc. 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 Na
'
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future b ding occupant use equipment or devices which
emit harardous air contaminants dcfincd by the Bay Area Air Quality Management
all new materials for inspection.
District?
We
❑ Yes
Ilia re e ousmaterials requirements under Chapter 6.95ofthe Califor-
nia Health & ofi C dons25505,25533and 25534.1understand datifthcbuilding
does not cu n y h a ant, that it is my responsibility to notify the 'ant of the
requiremen It 'St or to issuance OraCertifica ry.
Signature of Applicant Date
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All roof coverings to be Class','." or better
Owner or author
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