04030098 CITY OF CUPERTWO ._- ----- - '•�a a-
:DING
DIVISION PE IT CONTR &T(QR INFORMATION 2 - ----
r.a S.YYnjyy::.✓ RFEk.$a.?.x? ..5> H^F.'* .a ..f}. `"c'
BUILDIrvG ADDRess: CENTEX HOMES PERMIT ND04030098
IER'S NAME: PERMIT LSSUE DATE
ONE: - SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT" PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION Job De$CrlpuUn
C 1 hereby affirm that I'am licensed under provisions of Chapter 9(commencing
I! wlNSecsia tmelC7 of Divi6ionJo the Business andProRsi ,p/e license is
n In:C.fomeands (Jy /fes
Lx,en Lm.n � �'-- SFDWL-3 STORY (PLAN 5)
F w DoE,TS DEC1992
RCHnECI'S DECLARATION LIVING /GARAGE SQ FT C .r
-I I undersand my ns shall W umd es public records
:---
3 a Licensed Professional Q n
`x,� OWNER-BUILDER DECLARATION e7f7 t•
I I herehy own.that I am exempt from the Cantncsars License Law(ac the
O f o following reason.(Sadao W131.5.Business and Professions Cade:Any city or county
3 which acquires,a permit m conon s,eller,improve.demuluh,Or repair any nmcmre
Nicam its ism..ce.also requi.O.spplicam far such permit l9 file.s,rusl Catemem ., vs
x< that he is licensed pursuant to Ibe provisions of me COntracmr's License Law(Chapter 9 ,. .,. .. Sq. Ft.Floor Area V L y g (00 1,
�th (commencing with SectionIRIM)of Division 3 of the Businesaand Profassions Code)., \- vy-
$ that Im is exempt therefrom and the basis for the alleged exemption.Any violation of
Section]O11.5 by any applicant fon permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more man five hundred dollars(S5W).
as owner of me property,or my employees with wages as mew sole compensation, 36619076 . 00
--- — -'-�
da thevem"..nameswctamites.,imm.dedarofremdf.,s0.(Sa.?aa.Bauneas - - Required Inspections "
and Professions Code:The Contractor's Liana Law docs not apply to an owner of - q P -
property who builds or improves Beacon,and who doessuch work himself or through his
ownemployeea pmvided mal such improvements acenotimended mothered forsole.If, - - - -.
however,the building or improvement is sold within m¢yea a(coopiction,the center-
builder will have the burden of proving mu he did not build or improve for Pumase of
sole.).
❑I,as Owner of the property,am exclusively contracting with licensed contractors to . .
construct Oc project(Sec.7W,Business and Professions Code:)The Cenmcmr's Li- -
cense law docs not apply in an owner of property who Wilds or impmves themon.ad -
whocontractsforsuchprojectswithacormacsor(s)licensed pursuant m the Contractor's
Licca¢law.
El I.cn exempt under Sne. .B&PC for this mason
Or Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRren under penalty of perjury ane of the(thawing declarations: -
Iha.a imovidl far
SeCm.37Mof the Labor udle.frreo, -
woukfas pmvided for by Section 3]BO of the labor Cade,fm the peAormnnce of the
wick for which this permit is issued. _
I have and will maintain Worker's Compensation Insurance,as required by Section -
37BO of the Labor Code,for the performance of m.work for which this p.it is issued.
C nW�rkeh onln� canter an PalicY ymbc
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W complced i(the Permit is Intone hundred dollars(SIM)
or Ices.)
I certify mat in the peafnmmone of she work for which this Permit It issued,)shall not
employ any person in any manner so as m bccomc subject m the Workers'Compensation ..
laws of Califomia.Dale
Applicam
NOTICE TO APPLICANT:If,after making this Ccuifieam of Exemption,you should
become subject to the Workers Compensation provisions ofthe Ichor Code,you must
.,z forthwith comply with such pravisian.Or this permit shall W deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
'Tr+ .�., I hereby alirm Out mere is a mmsmction lending agency for IM performance of -- -
x the walk for which this permit is issued(Sec.VD,ON.C.)
W Q Lenders Name - -
IY fender's Addreas
D z �——
U C I e otify that 1 have mad this application and sax,that the above information is \
W F" Correct.1 agree in comply with all city and county on inaaen and sate laws relating to .
0U building Conswction.and hereby amhorire eepecturchoor_s of this city to enter upon me
} W alsove-mentioned property for imptchon puaposea
(We)agree to save,indemnify and tamp harmless the City of Cupertino against
Hh liabilities,judgmenu,msu and expenses which may in any way acemc againstsoid City
U in consequence of she granting of this permit t
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTis
sued by: Dat_ _
OU REG ATION - -
Re-roofs
Signature of Applic%n y actor Date
H(QARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or furore building Occupant atom or handle hvardous material
as defined by the Cupertino M<al Code.Chapter 9.11,and this Health and Safety
c.Sccsion25511(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Y Nu
Will mea bean or future building ora aril use equipment are daces which If a roof is installed without first obtaining an inspection,I agree to remove
PP 6 p 4uipmc
mit hmardaus air contaminants as defined by the Bay Am.Air Quality M....comm all new materials for inspection.
Diuric0
pIts
1 have read the hvatdlws mawrials mquimnenu un&rChapter6.95O(me Califor-
niaHcslm&SarctyCOdc,Satiom15M5.n533arvs]5534.lundcaa ifde Wilding
does nml currently Aare a renanL that it it MY maponsihility x,rodfy the aruPanl n(mc
m nim beth riatWi .Ccnirmateor up' Signature of Applicant Date /V///
Owner ter atrmoriv. agcm Bout All roof coverings to be Class "B"or better